22-23 Covid-19 Positive Case Report

Covid-19 Positive Case Report
Email *
example@example.com
Relationship to Trinity

Family (Parent/Student) Volunteer
Name of Positive Case *

First Name Last Name
Student Grade *
Student Homeroom *
Birthdate *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Date symptoms started: *

Month Day Year
Date
Current Symptoms (Choose All That Apply) *

Asymptomatic Fever Shortness of Breath or difficulty breathing New loss of taste or smell Cough Congestion or runny nose Headache Nausea or Vomiting Sore Throat Muscle/Body Aches Fatigue Diarrhea
Fever Temperature
Date test was taken: *

Month Day Year
Date
Date test was resulted: *

Month Day Year
Date
Last date on campus: *

Month Day Year
Date
Any after school or before school activities at Trinity? (please list activity and date)
Did you attend any church events? (Please list activity and date)
Best person to call: *
Best phone number to call: *

Area Code Phone Number
Hospitalization Status *

Never Hospitalized Currently Hospitalized Discharged Unknown
Current Hospital
Testing Location (Include Complete Address) *
Testing Physician Name *
Contact Information for Physician *
If you are submitting this form for a student - please read below:

Zoom is now requiring us to get your permission to allow your child under the age of 13 permission to use the Zoom platform. If your child is in grades 4-8 please check below, allowing your child to use Zoom.

If you are submitting for a child in grades K-3, please disregard.
Yes, my child is in grades 4-8 and I approve of them use Zoom for their E-Learning.

Yes, my child can use Zoom No, my child cannot use Zoom
Should be Empty: