School COVID Close Contact Notification Form
Use this form to notify the school about a possible or confirmed close contact COVID exposure and provide the details needed for follow-up.
Exposure Notification Details
Date of Notification
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person Notified About
*
Student
Staff Member
Visitor
Other
Full Name
*
First Name
Middle Name
Last Name
Role / Grade or Class
School Name or Campus
*
Date of Last Close Contact Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Exposure
Close Contact Status
*
Confirmed
Suspected
Unknown
Contact Information
Parent/Guardian or Reporter Full Name
*
First Name
Middle Name
Last Name
Relationship to Student/Person
*
Please Select
Parent
Guardian
Reporter
Other
Preferred Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Best Time to Contact
*
Morning
Afternoon
Evening
Anytime
Health and Attendance Information
Currently showing symptoms?
*
Yes
No
Unsure
Symptom start date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current attendance status
*
Attending
Absent
Isolating
Sent home
Unknown
Additional health-related notes
School Follow-up Details
Has the person been tested for COVID-19?
*
Yes
No
Scheduled
Unknown
Test date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Test result
Positive
Negative
Pending
Unknown
Should the school initiate contact tracing or provide next-step instructions?
*
Yes
No
Unsure
Additional people at the school who may also need notification
Submit Notification
Should be Empty: