Intro

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Intro

Please fill out the following form, (ONE FORM REQUIRED PER PERSON PER EXPOSURE/POSITIVE TEST RESULT) This will help in our contact tracing, as required by the Virginia Department of Health. All responses are 100% confidential between you and the RCS Director of Health Services and would only be shared on an as-needed basis. Your privacy is protected by HIPAA laws and regulations. I am here to help ensure we uphold those laws and regulations and keep our school community safe and healthy.

Stephanie Wimbish BSN, RN, CMHFA
Director of Health Services

Are you filling this form out for yourself or someone else? *

Myself

Someone Else

What is the name of the person who was exposed or tested positive? *

Are you reporting a positive COVID19 test result or an exposure to someone who tested positive? *

Positive Test Result

Exposure

Both

Date of positive test? (If only exposed, please skip)

YYYY

Date of exposure? (If positive test result, please skip)

YYYY

Is anyone in your household employed by RCS? *

Yes

Does the person who exposed you to COVID19 attend RCS? *

Yes

If you know who exposed you (and they attend/work at RCS) please name them below (contact tracing purposes only) *

When were you last on RCS property? *

YYYY

Please list any symptoms you are experiencing and when symptoms began *

Are your symptoms improving, staying the same, or getting worse? *

Improving

Staying the Same

Getting Worse

Does the person who tested positive/was exposed participate in any RCS sponsored extracurricular activities (Sports/Clubs/Etc)? If so, please list below *

Do you plan on getting a COVID19 test? (recommended 5 days after exposure) *

Yes

Have you spent anytime unmasked (inside or outside) within 6 feet of any student or RCS employee? *

Yes

Have you spent any time masked within 3 feet (inside or outside) of any student or RCS employee? *

Yes

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