Household Close Contact Quarantine COVID-19 Reporting Form / Formulario informativo de Contacto Cercano en Casa COVID-19 Cuarentena

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Please complete one form to report quarantine for each Lake Travis ISD student that has been deemed a household close-contact. / Por favor complete este formulario por cada estudiante de Lake Travis ISD que haya tenido contacto cercano.

Email *

Student Grade Level / Nivel de grado del Estudiante *

Campus/ Escuela *

Student Last Name / Apellido del Estudiante *

Student First Name / Nombre del Estudiante *

Person Reporting/ Persona reportando *

Contact Phone Number for Person Reporting/ Numero de telefono de la persona haciedo el reporte

Student's relationship(s) to COVID-19 positive individual(s) in the household (i.e. parent, school age sibling or non-school age sibling, or grandparent). Que relacion existe entre el estudiante y la persona que resulto positivo con Covid-19 en su hogar. (Hermano, padre, abuelo, etc)

Last date of contact with COVID-19 positive individual? Fecha de la ultima vez que tuvo contacto con la persona que dio positiva a COVID-19? *

YYYY

Has the Student tested positive for COVID-19 in the last 90 days or is fully vaccinated? En los ultimos 90 dias, su estudiante ha dado positivo a una prueba de COVID-19 o ha recibido la Vacuna?

Fully Vaccinated (2 doses plus 2 weeks) / Completamente vacunado (2 dosis más 2 semanas)

Tested Positive for COVID within past 90 days / Dio positivo por COVID en los últimos 90 días

Fully vaccinated AND has tested positive for COVID within the past 90 days / Completamente vacunado y ha dado positivo por COVID en los últimos 90 días

Neither of these situations apply to my child / Ninguna de estas situaciones se aplica a mi hijo

Other:

Clear selection

Is the Student symptomatic? Ha tenido algun sintoma su estudiante?

Yes /Si

Clear selection

Have you already made contact with the school nurse? Ya se comunico con la enfermera de la escuela?

Yes /Si

Clear selection

Send me a copy of my responses.

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