HIGH SCHOOL COVID Case Assessment

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Please fill out the following assessment form for your COVID positive child.

Today's Date *

YYYY

Last Name of Positive Person *

First Name of Positive Person *

Home Address (Ex. 111 West Street, Stewartville, MN, 55976) *

DOB - Date of Birth *

YYYY

Parent Last Name *

Parent First Name *

Phone Number (Most Accessible) *

Grade Level of Student *

Last Date Student was on campus for any reason *

YYYY

Which class periods were you not on campus for on your last date present? Check all that apply.

I was present for all class periods

1st period

2nd period

3rd period

4th period

5th period

6th period

7th period

8th period

Symptom Onset Date (Date symptoms started) *

YYYY

COVID Testing/Swabbing Specimen Collection Date *

YYYY

Does this person work or attend Tiger Time? *

Yes

Required

Did this person ride the bus within 48 hours prior to test date or of symptom onset date? (to school or home from school) *

Yes

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