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PVSD Health Services - Report of COVID Form
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student Building
*
Choose
Evergreen Elementary
Schwenksville Elementary
Skippack Elementary
South Elementary
Middle School East
Middle School West
PV High School
Student Grade
*
Choose
Grade K
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Parent First Name
*
Your answer
Parent Last Name
*
Your answer
Parent Contact - Phone
*
Your answer
Parent Contact - Email
*
Your answer
Last date student attended onsite classes and/or activity
*
MM
/
DD
/
YYYY
Did the COVID positive student experience any signs or symptoms?
*
Yes
No
Symptom Start Date
*
MM
/
DD
/
YYYY
Date of COVID test taken - provide date or indicate No test
*
Your answer
Type of COVID test taken
*
PCR
Rapid Antigen
Testing not advised
List Sports or ExtraCurricular Activities the Student is Involved In
Your answer
List Siblings in the District (including name, grade, building)
Your answer
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