Report Your Child as a CLOSE CONTACT

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This form should only be used to report a Student who has recently been identified as a CLOSE CONTACT with a person who tested Positive for COVID-19 within two days of your child's last exposure to them.

CLOSE CONTACTS may include: a family member presently living in your home, or anyone your child spent 15 minutes or more with, within three feet of that person with COVID-19 over a period of 24 hours.

*Please fill out this form for each child affected.
**We are continuing to follow our local Health Department Guidelines for schools that recommends "Close Contacts" to quarantine for 10 days from the date of their last exposure to the Positive person, unless they too become "positive," which may change the quarantine time period.

Student's Last Name *

Student's First Name *

Parent/Guardian(s) First and Last Name(s) *

Date of student's last exposure to person testing positive for COVID-19. *

YYYY

Is the COVID positive person living in the same household? (If "Yes," Explain whether they are being isolated from your child or not) *

Does your child currently have any signs or symptoms related to COVID-19? *

If you answered "yes" above for symptoms, please place a checkmark beside the symptoms your child has or has had recently. *

Fever

Sore throat

Cough (some cause difficulty breathing)

Diarrhea

Nausea or vomiting

Abdominal/stomach pain

Headache (possibly severe)

New loss of taste or smell

Runny nose

Congestion

Chills

Muscle pain

Shortness of breath

Repeated shaking with chills

Tiredness

Rash

Muscle Aches

Weakness

My Child Did NOT have any symptoms

Other

Required

If you marked "Other" above, please explain the symptoms.

Has your child been tested for COVID-19? (Yes/No and Please list the date(s) tested and results found for each date) *

Were you told by a Health Professional how long he/she would need to quarantine? And/or told what date your child could return to school? Please explain! (Please note: Queen of Angels reserves the right to make the final determination on the date of return for your child.) *

Child's Grade Level *

PK3

PK4

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

Child's Home Street Address *

Child's Home City Address *

Child's Home State Address *

Child's Home ZIP Code *

Child's Birth Date *

YYYY

Best Contact Phone Number (and name of the person at this number) *

Best Contact Email Address (and name of the person at this address) *

Please check mark other activities your child is involved in at school. *

Before Care/After Care

Athletics

Other

No Other Activities

Required

If you checked "Other" above, please list the activities your child recently participated in.

What was the last day this student was in school? *

YYYY

Does this child ride with other children to or from school? *

Yes

If you answered "Yes" to the question above, name any other students who rode in the same car with the your student and the last date they rode together: (in case we have to do later contact-tracing)

Any other information you would like to share. (i.e. Is your child vaccinated? If so, please record the date of their last immunization) If you have no information to share please type "N/A") *

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