JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Student Sickness / Exposure Report Form
Please fill out this form if your student has been exposed to COVID-19, tested positive for COVID-19, or is feeling sick.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Student Name (First Name, Last Name)
*
Your answer
Students Grade
*
Your answer
Students Date of Birth
*
MM
/
DD
/
YYYY
Student's Homeroom Teacher
*
Your answer
Please describe the symptoms your child is experiencing.
*
Your answer
Date of exposure to COVID or Illness. Please explain.
*
Your answer
Last day student was on campus
*
MM
/
DD
/
YYYY
List anyone that you are aware of that has been in close contact to your child.
*
Your answer
Date of COVID Test (if applicable)
MM
/
DD
/
YYYY
Result of Covid Test (if applicable)
Positive
Negative
Other:
Clear selection
Has the student tested positive for COVID-19 in the last 3 months? Please explain.
*
Your answer
Name of Person Completing Report (First Name, Last Name)
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Preferred Method of Contact
*
Email
Phone Call
Text Message
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of GOCAcademy.
Report Abuse
Forms
