Self-Reporting Form for a Student Diagnosed with COVID-19

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This form should be used to report when a student has tested positive for COVID-19. Once the report is received, the school nurse will contact you with additional information if needed.

Westlake Academy will treat this information as confidential to the fullest extent allowed by state and federal law.

PLEASE NOTE: We are obligated to notify Tarrant County Public Health if an individual with COVID-19 or tested positive for COVID-19.

Email *

Name of person submitting report *

Contact number of person submitting report *

Student First Name *

Student Last Name *

Grade *

Please state the date when the student started showing COVID-19 symptoms *

YYYY

Please state the date when the student received a positive COVID-19 test result *

YYYY

Please state the date the student was last on campus *

YYYY

Are there any other family members who tested positive?

Is there any other information you believe we need to know?

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

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