Benton School District COVID-19 Screening Form
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Is the patient a student or staff member? *
Patient First Name *
Patient Last Name *
Patient Phone number *
Patient Email Address *
Patient Emergency Contact/Parent/Guardian Phone number *
Patient Emergency Contact/Parent/Guardian First Name *
Patient Emergency Contact/Parent/Guardian Last Name *
Patient is assigned to which building? Check all that apply. *
Required
Patient's first date of known symptoms, if any
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Date of contact with confirmed positive COVID-19 case
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DD
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YYYY
Does the positive case reside within your home?
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Date of patient confirmed COVID-19 positive diagnosis result, if applicable.
MM
/
DD
/
YYYY
Please check all buildings the patient may have entered in the last 48 hours.
Please list any school activities or school events the patient has participated in during the last 48 hours. *
Please explain how you think the patient may have contracted the virus. *
Please provide any information that may be helpful.
The Benton School District COVID-19 Point of Contact will contact you via email or phone, if additional information is needed. You may also be contacted by phone from the Arkansas Department of Health. This report assists Benton School Officials in guiding you regarding school attendance and is not a replacement for medical advice from your health provider. If you are experiencing COVID-like symptoms or have been exposed to COVID-19, please also contact your health provider.
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