COVID-19 Questionnaire

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Dear Families,

Please use this form to report any necessary COVID-19 related information to the nurses' office regarding a student or impacted member of faculty or staff. If you have any health-related questions regarding COVID-19, we encourage you to contact your primary care physician. If you have further questions, please note them here and someone will get back in touch. Thank you for your partnership in keeping our school safe!

* Please complete a separate form for each report

Email *

Grade or designation *

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Faculty

Staff

Student's Advisor/Primary classroom teacher

Student/Employee Last Name *

Student/Employee First Name *

Has this individual been diagnosed with Covid in the past 90 days?

Yes

Clear selection

Is the individual having any of these symptoms (please check all that apply)?

Fever greater than 100.0

Sore throat

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headaches

Chills

Loss of taste or smell

Congestion or runny nose

Nausea or vomiting

Diarrhea

When did symptoms start?

YYYY

What date was the individual last on campus?

YYYY

Has the individual tested positive for COVID-19?

Yes

Clear selection

What was the test date of the positive Covid test result? *

YYYY

Send me a copy of my responses.

Submit

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