Middle and High School STUDENT - COVID Reporting Form

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This form should be used by parents and guardians to report any and all student issues related to COVID. Once you complete the form you will be contacted by a School Nurse within 24 hours of completing this form during the week, and on Monday if this form was completed during the weekend.

If your child has tested positive, is awaiting test results, or has been exposed to this virus DO NOT send your child to school until he or she has been cleared to return by the school nurse and an attestation form has been completed. You will need to report your child's absence in addition to completing this form.

You can update the RI Department of Health on your child's status and schedule testing for your child by calling: 1-844-857-1814

Email *

Student LAST Name, First Name *

Student date of birth *

YYYY

Location: name of school *

Classroom Teacher Name *

Does the child have any siblings other relatives/children living in the house that attend Warwick Public Schools? If Yes please complete a form for each child. *

Yes

If YES to the question above please give sibling name, grade and school attending *Please complete a form for each child*

Parent Name *

Parent Contact Info: home, cell, or work phone numbers *

COVID Status (check all that apply) *

Symptomatic - absent out of abundance of caution

Symptomatic - not yet tested

Symptomatic - awaiting test results

Asymptomatic and/or close contact - awaiting test results

COVID Positive rapid test result

COVID Positive PCR result

Isolation by RIDOH

Quarantine by RIDOH

Close contact of COVID positive person

Travel to a state with a 5% or greater positivity rate

Required

COVID Rapid Test Positive Date (if known)

YYYY

COVID PCR Test Positive Date (if known)

YYYY

Date of close contact of COVID positive person

YYYY

If student is symptomatic, please check all the apply

cough

shortness of breath

difficulty breathing

new loss of taste and/or smell

fever

chills

muscle aches

headache

sore throat

nausea and/or vomiting

diarrhea

fatigue

congestion or runny nose

Other:

Date of first symptoms

YYYY

Last date in school (in person) *

YYYY

If required to be in isolation by RIDOH, please indicate the start date

YYYY

Isolation by RIDOH end date

YYYY

If required to be in quarantine by RIDOH, please indicate the start date

YYYY

Quarantine by RIDOH end date

YYYY

If the student was a close contact (closer than 6 feet for more than an accumulated 15 minutes) of a positive case, is the person

A family member living in the same home

A family member or other person that the student does not live with

Other:

Clear selection

Anticipated return to school date (leave blank if unknown)

YYYY

Is the student able to participate in Distance Learning during absence? *

Yes

Unsure at this time

As required, I have reported my child's absence to the school *

Yes

Additional Comments

A copy of your responses will be emailed to the address you provided.

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