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Crim School COVID-19 Reporting Form
Parents/Guardians,
Please complete this Form as soon as possible so we can take the necessary precautions to help prevent additional virus exposure. Please complete a separate form for each student.
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* Indicates required question
Email
*
Your email
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Student's Grade Level
*
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Student's Homeroom Teacher(s)
*
Your answer
Which would you like to report?
*
My child has tested positive for COVID-19
My child has symptoms of COVID-19
My child has been in close contact to a COVID-19 positive case
Someone in our home has tested positive for COVID-19
Someone in our home is awaiting results of an outstanding COVID-19 test
Required
Is your child fully vaccinated (2 weeks post second dose)?
*
Yes
No
Last day your child was in school
*
Your answer
Date symptoms first appeared
*
MM
/
DD
/
YYYY
Symptoms
*
Your answer
Date of exposure (if known)
MM
/
DD
/
YYYY
Location of exposure (if known)
Your answer
Date of positive test (if applicable)
MM
/
DD
/
YYYY
Please list any siblings in the district and their current school. Please indicate whether the sibling is fully vaccinated.
Your answer
Can your child isolate away from others at home?
*
Yes
No
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