Student or Staff COVID Concern Report
Childcare Name
Childcare Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Childcare Contact Name
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Contact Email
example@example.com
What type of concern is this?
Student sent home with illness/symptoms
Staff member sent home with illness/symptoms
Student tested positive for COVID-19
Staff member tested positive for COVID-19
Student had close contact with someone who tested positive for COVID-19
Staff member had close contact with someone who tested positive for COVID-19
Date the student/staff member of concern was last in the facility:
-
Month
-
Day
Year
Date
Name of person who was ill or tested positive
First Name
Last Name
Submit
Should be Empty: