COVID-19 Positive Case Reporting Form

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

Date Form Completed*

Answer required for "Date Form Completed"

Confirmed/Suspected Case Demographic Data

First Name (Confirmed/Suspected Case)*

Answer required for "First Name (Confirmed/Suspected Case)"

Last Name (Confirmed/Suspected Case)*

Answer required for "Last Name (Confirmed/Suspected Case)"

Middle Name (Confirmed/Suspected Case)*

Answer required for "Middle Name (Confirmed/Suspected Case)"

Last Date Present at School*

Answer required for "Last Date Present at School"

Date of Birth (Confirmed/Suspected Case)*

Answer required for "Date of Birth (Confirmed/Suspected Case)"

Age (Confirmed/Suspected Case)*

Answer required for "Age (Confirmed/Suspected Case)"

Ethnicity (Confirmed/Suspected Case)*

Answer required for "Ethnicity (Confirmed/Suspected Case)"

Hispanic/Latino

Non-Hispanic/Latino

Not Specified

Race (Confirmed/Suspected Case)*

Answer required for "Race (Confirmed/Suspected Case)"

Caucasian/White

African-American/Black

Asian

American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

Other:

Sex (Confirmed/Suspected Case)*

Answer required for "Sex (Confirmed/Suspected Case)"

Male

Female

Name of Point of Contact (if student is confirmed/suspected case, list Parent/Guardian)*

Answer required for "Name of Point of Contact (if student is confirmed/suspected case, list Parent/Guardian)"

Phone Number of Point of Contact*

Number Required

Phone Number Type of Point of Contact*

Answer required for "Phone Number Type of Point of Contact"

Home

Cell

Work

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Disease/Symptom Data

Date of symptom onset:*

Answer required for "Date of symptom onset:"

Date of positive test result:*

Answer required for "Date of positive test result:"

Hospitalization and Clinic Data (If Available)

Hospitalization Status:

Answer required for "Hospitalization Status:"

Never Hospitalized

Currently Hospitalized

Discharged

Unknown

Testing Location:*

(Include Complete Address)

Answer required for "Testing Location:"

Testing Physician:*

Answer required for "Testing Physician:"

Contact Information for Physicians:*

Answer required for "Contact Information for Physicians:"

Please fix the highlighted areas below before submitting.

COVID-19 Positive Case Reporting Form