St. Michael's 2021-22 COVID-19 Reporting Form

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Thank you for your proactiveness to alert us. By doing so, you are helping protect others in our school community. As COVID mimics the symptoms of many other illnesses, please fill out this form any time your child or a family member is ill.

The information you share below will only be shared with the St. Michael's COVID-19 Task Force and be kept CONFIDENTIAL. Nurse Maben will reach out to you to discuss your case.

***** IMPORTANT NOTE: If you submit your COVID form after hours or on weekends, please keep your child(ren) AT HOME until you hear from Nurse Maben. Nurse Maben will respond by the end of the next school day.*****

(Any questions? Nurse Maben's contact info is 804-272-3514, x 110, smaben@stmschool.net.)

Please submit 1 report per PERSON - NOT per family.

FIRST AND LAST NAME *

Phone Number (best # to reach you) *

Email Address *

I am reporting an exposure for: *

Myself

A member of my household

Other:

If you selected "a member of my household" above, please provide their name (and if student, their teacher and grade)

Within the past 14 days, I have / my household member has (check all that apply): *

tested positive for COVID-19

been exposed to someone that has COVID-19 (note: the CDC defines exposure as "contact less that 6' for 15 minutes or more, without a face covering")

completed a COVID-19 test and am awaiting results

been exposed to someone who has completed and is awaiting COVID-19 test results (note: the CDC defines exposure as "contact less that 6' for 15 minutes or more, without a face covering")

developed COVID-19-like symptoms and quarantined (either voluntarily or by doctor recommendation)

Other (please explain scenario below)

Required

If answered "OTHER" above, please explain the scenario.

When was the last date and time you/your immediate family member was on campus?

Date: *

YYYY

Time: *

Time

Other details regarding this exposure that might be helpful to our COVID-19 Task Force?

Does your family carpool with other St M families? If so, please list families and circumstances below.

THANK YOU for informing us and helping keep our St M community safe. Nurse Maben and/or a Division Director will reach out to you by phone to discuss any needs and next steps. Please keep your children(ren) home until contacted by Nurse Maben. --If completing the form on the weekend, you will be contacted on the next business day. Thank you again for your support and partnership.

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