COVID-19 Confirmed/Probable Case Reporting Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Waimalu Elementary is requesting your assistance to streamline and account for all positive COVID-19 cases. Please complete this form if your child has received a positive test result from a certified lab or if s/he has a known exposure and tests positive on a home test kit. All information collected will be kept CONFIDENTIAL.

Student's Name (Last, First) *

Grade Level *

Pre-K

Kindergarten

First

Second

Third

Fourth

Fifth

Teacher's Name

Parent/Guardian's Name (Last, First) *

Phone Number *

Date last on campus: *

YYYY

Does your child attend morning care, A+, and/or ride the bus? *

Attends Morning Care

Attends A+

Rides the bus in the morning

Rides the bus in the afternoon

None of the Above

When did your child first exhibit COVID-19 symptoms? If asymptomatic, enter N/A *

What was the date of the POSITIVE COVID-19 test? *

YYYY

What is your child's current vaccination status (For DOH reporting purposes only)?

Fully Vaccinated

Partially Vaccinated

Unvaccinated

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Hawaii Department of Education. Report Abuse

Forms