Neff~ Student COVID Data Entry Form
Please complete the following form to report suspected or confirmed cases of COVID 19.
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Email *
Today's Date *
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Date of first student absence related to COVID (Type NA if student has not missed school yet). *
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Student Last Name, First Name *
Student ID without the "S" (also known as Lunch ID) *
Grade *
Is the student involved in Extra Curricular Activities?  If so please list, if not please type NA *
Parent/Guardian's Name and Relationship to student: Last Name, First Name, Relationship (Mother, Father, Grandparent, Guardian, etc) *
Phone Number *
Email *
Has your student had a known exposure to COVID 19 in the last 2 weeks?  Type Yes or No.  If yes please include the date of last exposure *
What type of exposure was your student exposed to? *
Symptoms: *
Please select any and all symptoms the student may be having.  If student is not having symptoms select None.
Required
Start Date for Symptoms (Please type NA if student does not have symptoms.) *
Last Date on Campus or at NISD Event *
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Vaccinated Status: *
Name of Vaccine: *
If not vaccinated select NA
Required
Date of last dose of vaccine *
If not vaccinated enter NA
COVID Test Date (Type NA if you have not been tested) *
COVID TEST Results *
Type of COVID Test *
I know and understand that I need to email all test results to the Campus Nurse, Jenifer Rasti @ jenifer.rasti@nisd.net *
I know and understand that I need to email all doctor's notes and medical documentation for this case to the Campus Nurse, Jenifer Rasti @ jenifer.rasti@nisd.net AND attendance secretary, Melinda Zaragosa @ melinda.zaragosa@nisd.net *
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