COVID-19 Information Form

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

An open and honest dialogue is needed in our community for all us to share in the responsibility of keeping our community safe. It's important we don't participate in hearsay. Please, only fill out this form if you believe that you, your family, or friend you know first hand, has been exposed to COVID-19. The intention of gathering this information is to prevent transmission of the virus and to keep our community safe.

Email *

Your First Name: *

Your Last Name: *

Phone Number:

Preferred Contact Method:

Phone

First and Last Name of Person (s) Exposed to COVID-19: *

Relation to person filling out form: *

Does this person have symptoms or does not feel well? *

Yes

When did the symptoms start?

How do you think this person or persons was exposed?

Any additional comments / questions / concerns:

Please provide any other information you feel may be relevant or you would like us to know.

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of CASADY SCHOOL. Report Abuse

Forms