WES COVID-19 Reporting Form

This form is for school notification purposes. Please contact your medical provider for medical care and treatment.

This form is for reporting COVID-19 positive cases diagnosed by a health care professional or a test performed by a testing site, or for those identified as a close contact (within 6 feet for 15 minutes in a 24-hour period) to a positive COVID-19 case.

The information contained in this form is confidential and will be directed to your School Nurse. A nurse will contact you within 48 hours for verification of this information and discuss DHEC/CDC and school district guidelines with you.

By submitting this form, you are verifying that the information provided is accurate and true to the best of your knowledge.

Are you a parent/legal guardian reporting for your child or an employee reporting for yourself?

Parent/Legal Guardian Employee

Employee Name

First Name Last Name

Job Title

Are you positive or a close contact to a positive case?

Positive Close Contact to a Positive

Parent / Guardian Name

First Name Last Name

Phone number where you may be reached (with area code)

Please enter a valid phone number.

Email Address where you may be reached

example@example.com

Is the student positive or a close contact to a positive case?

Positive Close Contact to a Positive

Date of positive diagnosis or date of last contact with a positive case

Month Day Year

Student Name

Legal First Name Legal Last Name

Grade Level:

Pre-Kindergarten Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Birthdate

Month Day Year

Home Address

Street Address

Street Address Line 2

Postal / Zip Code (For Statistical Data)

COVID-19 Reporting Form

Employee Information

Parent / Guardian Reporting for a Child

Student Information