FORT WORTH CHRISTIAN SCHOOL
ILLNESS ASSESSMENT FORM

*Please complete the form below as completely and accurately as possible.

*If reporting on another individual, please keep all information strictly confidential.
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Email *
Date of this report *
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1) This report is about a (select one) *
2) Who is making this report? *
3) Information of person making this report (Please include first name, last name, role at FWC (ex: student, staff, or family member) *
4) Contact phone number of the person making this report: *
5) Information on the individual who is affected by COVID-19 (Please include first name, last name, and role at FWC (ex: student, staff, or family member) *If self-reporting, please type "same as #3" *
6) Is this individual who is considered positive for COVID-19 or under suspicion currently on FWC's campus? *
Required
7) Are there any symptoms present or signs of illness with this individual now or in the last 48 hours? *
Required
8) Please check any of the symptoms present or signs of illness for this individual: *
Required
9) Date when symptoms first appeared or noticed? *
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10) Can you confirm whether or not if this individual is currently under the care of a licensed physician for their COVID-like symptoms? *
11) What areas of campus did this individual visit while on campus from 48hrs prior to symptoms or signs of illness starting? If no symptoms present, unknown symptom status or date; then what areas on campus were visited after diagnosis, suspicion, or notification? (Please be as specific as possible so these areas can be properly disinfected as needed) *
12) If the individual is an FWC student, what in-person classes did this individual attend? (Date, class name, class period, and the teacher) If not a student, please explain *
13) Please check any other affiliations that this individual may be involved with outside of the actual classroom: *
Required
14) In the past 14 days, was there a known prior contact or exposure with the individual who is test-confirmed positive for COVID-19? *
Required
15) If known, please list the full name of the person(s) who possibly came in close contact (within 6ft for at least 15 minutes) with a test-confirmed positive or presumed positive individual. Include contact information for each person listed if known. *Use one line per individual. *
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The information collected in this report will be protected and kept private to the fullest extent possible. This information will be used by the FWC Medical Team and designated school administrators to help ensure the health and safety of our FWC community. Please ensure that you provided the most accurate information possible so that it can be used to help protect others.
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