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Covid-19
ONLY COMPLETE THIS FORM IF YOU HAVE TESTED POSITIVE FOR COVID-19 AND HAVE THE REPORT OR A PICTURE OF YOUR IN-HOME TEST
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* Indicates required question
Email
*
Your email
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Grade
*
9th
10th
11th
12th
Date of Covid-19 Test
*
MM
/
DD
/
YYYY
Test Type
*
At home test
Lab Confirmed Test
Surveillance Test
Date Symptoms Started
*
MM
/
DD
/
YYYY
Last time student was in the school building?
*
MM
/
DD
/
YYYY
Did the individual test positive in the last 90 days?
*
Yes
No
Unknown
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