OABA COVID-19 Tracking Form

OABA COVID-19 Tracking Form

Confirmed or Suspected Case Information for Odyssey Academy Bay Area
Name of Person Who Is Confirmed or Suspects COVID-19:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
Format: (000) 000-0000.
Email:*
example@example.com
Date of Birth:*

MonthDayYear
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite (Hispanic or Latino)White (Not Hispanic or Latino)
MaleFemale
Which OA school do you belong to?*
StudentStaff
What grade level are you in?*
How old are you?*
Who is your home room and/or 1st period teacher?*
YesNo
YesNo
Please list what before/after school activities you participate in:*
What was the last day you were on campus?*

MonthDayYear
COVID-19 MEDICAL INFORMATION
Confirmed that I have itI suspect that I might have itI have come in close contact with someone who has it
YesNo
What was the date the close contact was tested for COVID-19?*

MonthDayYear
YesNo
FeverChillsRigorsMyalgiaHeadacheNausea or VomitingDiarrheaFatigueCongestion or Runny NoseSore ThroatShortness of BreathDifficulty BreathingNew Olfactory DisorderNew Taste DisorderOther
If you said yes to having symptoms, what date did they start?*

MonthDayYear
YesNo
Rapid (Results in 15 mins)PCR (Results in 48-72 hours)
What was the date of your COVID-19 test?*

MonthDayYear
PositiveNegative
If you have your test result, you can upload it here:

Cancelof
VACCINE INFORMATION
YesNo
PfizerModernaJohnson & Johnson
Date of Dose #1:

MonthDayYear
Date of Dose #2:

MonthDayYear
Is there any other information that you think would be helpful for us to know?
Please verify that you are human:*
Should be Empty:

OABA COVID-19 Tracking Form

COVID-19 MEDICAL INFORMATION

VACCINE INFORMATION