* Required

Student Name*required

Current Grade*required

Symptoms Start Date*required (mm/dd/yyyy)

Symptoms*

Please check all that apply.​

Abdominal Pain  Chest Pain  Chills  Congestion  Cough  Diarrhea  Difficulty Breathing  Fatigue  Fever  Headache  Loss of Taste/Smell  Muscle Aches  Nausea  Runny Nose  Shortness of Breath  Sore Throat  Vomiting  Other 

Has the student been hospitalized due to COVID-19 symptoms?​​*

Yes  No 

Has the student been in close contact with someone with a confirmed COVID-19 diagnosis?*

Yes  No 

For COVID-19, this student is:*

Vaccine - 1st dose  Vaccine - 2nd dose  Vaccine - Booster  Not Vaccinated 

Name of Person Completing Form:*required

Relationship to Student*required

Phone Number*required

Email Address*required