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 NameLast Name
Student Grade*
Student Homeroom*
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date symptoms started:*

MonthDayYear
Date
Current Symptoms (Choose All That Apply)*

AsymptomaticFeverShortness of Breath or difficulty breathingNew loss of taste or smellCoughCongestion or runny noseHeadacheNausea or VomitingSore ThroatMuscle/Body AchesFatigueDiarrhea
Fever Temperature
Date test was taken:*

MonthDayYear
Date
Date test was resulted:*

MonthDayYear
Date
Last date on campus:*

MonthDayYear
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 CodePhone Number
Hospitalization Status*

Never HospitalizedCurrently HospitalizedDischargedUnknown
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 ZoomNo, my child cannot use Zoom
Should be Empty: