COVID-19 School Reporting Form

This form should be used to report a student or staff member who is symptomatic, exposed or positive for COVID-19.

Is this a report about

School & Department Location of Staff or Student:

Your Name

First NameLast Name

Your Email

example@example.com

Your Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you completing this form for yourself or someone else?

You are

Other

Please give details

Symptoms, dates if tested, any close contacts etc.

The person you are reporting

Other

Please give details

Symptoms, dates if tested, any close contacts etc.

Name of the person you are reporting

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Student ID (if known)

Number

Parent/Guardian Name

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.