Staff Only Covid-19 Positive Case Report
Email
*
example@example.com
Name of Positive Case
*
First Name
Last Name
Employee Direct Supervisor
Employee Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
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
*
Submit
Should be Empty: