MIDDLE SCHOOL COVID-19 Case Assessment

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Please fill out the following assessment form for your COVID positive child.

Today's Date *

YYYY

Last Name of Positive Person *

First Name of Positive Person *

Home Address (Ex. 111 West Street, Stewartville, MN, 55976) *

DOB - Date of Birth *

YYYY

Parent Last Name *

Parent First Name *

Phone Number (Most Accessible) *

Grade Level of Student *

Last Date Student was on campus for any reason *

YYYY

Symptom Onset Date (Date symptoms started) *

YYYY

COVID Testing/Swabbing Specimen Collection Date *

YYYY

Does this person work or attend Tiger Time? *

Yes

Required

Does this person ride the bus to school or home from school? *

Yes

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