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Covid-19 Reporting Form

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

Please indicate whether this Covid-19 report is in reference to a District Six student of staff member?*

Answer Required

Student

Staff Member

Name of Student or Staff Member*

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What type of exposure are you reporting?*

Answer Required

Close Contact - The student/staff member has been around someone outside of his/her immediate family who tested positive for COVID-19.

Household Contact - Someone in the student/staff member's home has tested positive for COVID-19.

Positive Test - The student/staff member has tested positive for COVID-19.

If this report is in reference to a positive test result, please indicate the date of the student/staff member's positive test.

Answer Required

If this report is in reference to a student or staff member being a household contact, please indicate the date the household member tested positive.

Answer Required

If this report is in reference to a student or staff member being a close contact to someone outside of the home, please indicate the date that person received a positive test result.

Answer Required

Parent name - if in reference to a student.

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Preferred Contact Number*

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Email Address

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Is there any other information, related to this report, that you would like to share with us?

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Thank you for providing us with this information. We will be in contact with you soon.

If this is a medical emergency, please call 911 or your healthcare professional.

Confirmation Email

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