JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
COVID-19 Reporting Worksheet
Please submit one form for each student. If there is a required answer and it does not pertain to you, please write N/A.
Complete this form to submit your notification of a positive COVID test, a symptomatic individual, or known close-contact exposure.
Your information will be kept confidential. Thank you for helping to keep our SBS community safe.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Form Completed By - Parent Name:
*
Your answer
Form Instructions and Agreements
*
By checking this box, I acknowledge and agree to follow the instructions noted above.
Required
Phone Number:
*
Your answer
Home Address (Include City and Zip Code):
*
Your answer
Student Name:
*
Your answer
Please list all siblings that attend St. Bonaventure School (include their grade level).
*
Your answer
Student Birthdate
*
MM
/
DD
/
YYYY
Individual who has tested positive and/or is symptomatic:
*
Parent or family member living in the same household
Student
Other:
Required
Student's Grade and Attendance Room Teacher:
*
TK - Mrs. Muecke
TK - Miss Carey
Kindergarten - Ms. Day
Kindergarten - Ms. Skifstrom
Kindergarten - Mrs. Ourique
Grade 1 - Miss deHeras
Grade 1 - Mrs. Smith/Miss Gomez
Grade 2 - Ms. Wittels
Grade 2 - Mrs. Jojola
Grade 2 - Miss Scharf
Grade 3 - Mrs. Lewis
Grade 3 - Mrs. Swienton
Grade 3 - Mrs. Vu
Grade 4 - Mrs. deHeras
Grade 4 - Miss Nguyen
Grade 5 - Mrs. Viers
Grade 5 - Ms. Weston
Grade 6 - Miss Naughton (Attendance Room)
Grade 6 - Mr. Napoli (Attendance Room)
Grade 8 - Mrs. Wysokinski (Attendance Room)
Grade 8 - Ms. Rivera (Attendance Room)
Grade 7 - Mrs. Miller (Attendance Room)
Grade 7 - Mrs. Ciccoianni (Attendance Room)
Required
Has the individual displayed symptoms?
*
Parent/Family Member - Yes
Parent/Family Member - No
Student - Yes
Student - No
N/A
Required
Onset Date of Symptoms:
MM
/
DD
/
YYYY
Student Symptoms: Please check all that apply.
*
Fever (at or above 100.4)
Congestion/Runny Nose
Nausea/Vomiting/Diarrhea
Sore Throat
Headache
Fatigue/Muscle or Body aches
Cough
Difficulty Breathing
Loss of Taste/Smell
None of the Above/No Symptoms
Other:
Required
List all family members that have tested for COVID-19:
*
Your answer
Test Location (include complete address and phone number):
*
Your answer
If you used an FDA-approved home COVID test, please print and complete the "Parent Attestation Form" and submit the completed form, along with a photo/copy of the COVID test results to:
covid@stbonaventureschool.org
.
I acknowledge that I have read the instructions relating to the Parent Attestation Form (required by the school when using an at-home COVID test).
Type of COVID Test?
PCR/RNA/Molecular
Antigen
Atibody
Unkown
Specimen Source:
*
Nose Swab
Mouth Swab
Urine
Blood
Other
Required
Test Date:
*
Your answer
Test Result:
*
Positive
Negative
Awaiting Test Results
N/A
Other:
Required
Important: Send a copy or photo of test results to
covid@stbonaventureschool.org
.
*
I acknowledge and understand that the school has requested a copy of COVID test results. Send to:
covid@stbonaventureschool.org
.
Required
Has your child been exposed to someone known to have COVID-19? If so, please explain. Include the date and circumstances of the known exposure.
*
Your answer
Last day student attended school in person?
*
MM
/
DD
/
YYYY
Please let us know if your child is vaccinated for COVID-19
*
Yes; I have already submitted the record to the school.
Yes; I agree to email a vaccination record to the school within 24 hours
My child has started but not completed the vaccination process
My child is not vaccinated
I prefer not to answer
Other:
Required
Does the student participate in the Extended Day Program?
*
Yes
No
Required
How often do they attend Extended Day?
Your answer
Last day student attended the Extended Day program?
MM
/
DD
/
YYYY
Does the student participate in any school related after-school sports or clubs (team sports, cheer, etc.)? Please list:
*
Your answer
Does the student participate in any NON-SCHOOL related after-school sports, activities, or clubs (team sports, dance class, karate, cheer, etc.)? Please provide list:
*
Your answer
Does the student carpool with other non-family students to and from school?
*
Yes
No
Sometimes
Other:
Required
Last date your child carpooled with non-family students
MM
/
DD
/
YYYY
Is there any other information you would like to provide?
Your answer
OCHCA COVID Symptoms
OCHCA COVID Care Pathway
OVHCA COVID Definitions
Acknowledgement:
*
By checking this box, I acknowledge that I have read the OCHCA COVID Symptoms, Care Pathway, and Definitions provided above.
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of St. Bonaventure School.
Report Abuse
Forms
