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POSITIVE COVID-19 TEST Hampton Middle School
Thank you for letting us know your child is positive for COVID-19. Please answer the questions below to assist our school nurse with determining the date in which your child can return to school.
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* Indicates required question
Name of Person Completing Form
*
Your answer
Phone Number
*
Your answer
Parent email address
*
Your answer
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Grade
*
6
7
8
Is student exhibiting symptoms of COVID-19?
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Yes
No
Date Symptoms Started (Considered day 0) (If student did not have symptoms, enter your positive test date on next question.)
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MM
/
DD
/
YYYY
COVID-19 Test Date (This is day 0 if student does not have symptoms)
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MM
/
DD
/
YYYY
Type of Test
*
Home
Rapid
PCR
Other
If answered Other above, indicate how student is positive (for example, presumed positive due to another family member who tested positive and is having similar symptoms)
Your answer
Date student was last in building
*
MM
/
DD
/
YYYY
Who does the student eat lunch with?
*
Your answer
Does the student ride the bus?
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Yes
No
If student rides the bus, please list the name of any student they sat in the same seat with.
Your answer
If the student is car rider, what other students ride in the same car (if any)?
Your answer
List the sports or after school activities in which student participates.
Your answer
List the name and grade of any siblings in school that may have been exposed (if any)
Your answer
Thank you for completing this form. Have your student stay home from school until we contact you with a return date.
*
I understand that it may take up to one day for someone to contact me.
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