Reporting Form: Close Contact with a Covid Positive Individual

Please complete the form below. Required fields marked with an asterisk *

Student First Name*

Answer Required

Student Last Name*

Answer Required

Student Homeroom Teacher*

Answer Required

Is your child vaccinated?*

Answer Required

Yes, completed all required shots and final shot was more than 2 weeks ago, but less than 6 months ago

Yes, completed all required shots and final shot was more than 2 weeks ago, but more than 6 months ago

Partially, only received 1 of 2 shots or has not been 2 weeks since final shot

If have not yet submitted your child's vaccination card, please do so here.

Answer Required

Choose a file or drag it here.

Is the positive person fully vaccinated?*

Answer Required

Yes, completed all required shots and final shot was more than 2 weeks ago

Partially, only received 1 of 2 shots or has not been 2 weeks since final shot

Unknown

When was the last time your child came in contact with a Covid positive individual*

Answer Required

Does the positive person have symptoms? *

Answer Required

Yes

Please list the date symptoms began for the Covid positive individual

Answer Required

Testing date for the Covid positive individual*

Answer Required

Does your child have symptoms?*

Answer Required

Yes

If your child has/had any symptoms, please list them here

Answer Required

Has your child been tested?*

Answer Required

Yes

No but we will test

Testing Date

Answer Required

Does your child play on a CK sports team? *

Answer Required

Yes

What was the last day your child played or practiced with a CK team?

Answer Required

Please fix the highlighted areas below before submitting.