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COVID-19 Staff/Student Self Reporting Form
Complete the form below to make a COVID-19 report to Polk County Schools.
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* Indicates required question
Location
*
Benton Elementary
Copper Basin Elementary
South Polk Elementary
Chilhowee Middle
Copper Basin High School
Polk County High School
PILA
Central Office
Other
I am completing this form because:
*
I have been tested for COVID-19 or have been advised to be tested.
I have been in direct contact (6ft, >15 minutes) with a COVID 19 positive person.
I have symptoms of COVID-19.
Required
If you have been in direct contact with a COVID-19 positive person, when was the estimated date of exposure? (If this doesn't apply to you, please leave it blank)
DD
/
MM
/
YYYY
If you have symptoms of COVID-19, when did you develop noticeable symptoms? (If this doesn't apply to you, please leave it blank)
DD
/
MM
/
YYYY
If you have been tested, when was the date of test? (If this doesn't apply to you, please leave it blank)
DD
/
MM
/
YYYY
If you have been tested and it was not with the health department, where did you test? (This will help expedite the tracing process).
Your answer
If you have been tested and received the result, was it positive?
Yes
No
Clear selection
I am a:
*
Staff Member
Student
First Name:
*
Your answer
Last Name:
*
Your answer
Last four digits of social security number.
*
Your answer
Your email if you have one.
Your answer
Your phone number.
*
Your answer
Do you have any additional information about your report you would like to mention?
Your answer
Submit
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