Notification of COVID-19 Exposure

Parents and staff are urged to fill out this form as soon as they become aware of an exposure or a positive test result for themselves or a close contact - even after hours or at night. This information will be immediately sent to the nursing staff and administrators so that steps can be taken to protect other students and staff. Please be in touch with the nurse to determine when you can come back to school.

Names of Affected Students or Staff Member:

First Name *

Last Name *

Grade *

Staff or Student *

First Name

Last Name

Grade

Staff or Student

First Name

Last Name

Grade

Staff or Student

First Name

Last Name *

Grade

Staff or Student

First Name

Last Name

Grade

Staff or Student

Divisions: Please check all that apply: *

Covid-19 Information

Select those that apply

1. The person(s) listed above tested positive for COVID-19: *

Yes

No

Date Tested *

Date Symptoms Developed *

What date was this person last in school? *

Please provide as much information about the exposure as possible. *

2. The person(s) listed above has been exposed to someone that tested positive for COVID-19 or someone that is presumed to have COVID-19: *

Yes

No

Date Positive Individual Tested *

Date Positive Individual Developed Symptoms *

(If applicable) What date was this person last in school?

Please provide as much information about the exposure as possible. *

3. The person(s) listed above is under investigation for COVID19. *

Yes

No

Please state why: *

4. The person(s) listed above has a household member(s) who is/are under investigation for COVID19. *

Yes

No

5. Have you attended a Simcha without being both masked and social-distanced? *

Yes

No

6. Do you plan to attend a Simcha without being both masked and social-distanced?

Yes

No

What is the date of the Simcha? *

Parent Contact Information

Parent First Name *

Parent Last Name *

Parent Email *

Parent Phone *