Covid Test Results Submission Form
Please fill out this form to share Covid-19 test results with the Gibbons Nurse.
Questions can be emailed to Nurse@cghsnc.org
Please select the appropriate designation for the person whose test results are being submitted.
*
Grade 9
Grade 10
Grade 11
Grade 12
Educator
Off-campus coach
First and last name of person whose test results are being submitted.
*
First Name
Last Name
Student ID Number
Reason for the test?
*
Please Select
Exposure
Symptomatic
Athlete (Pre-test)
Drama Class (Pre-test)
Other
Athlete Select Sport (if applicable)
Please Select
Cheerleading (V)
Cheerleading (JV)
Cross Country Men
Cross Country Women
Dance Team
Field Hockey (V)
Field Hockey (JV)
Football (V)
Football (JV)
Football (9)
Golf Women
Soccer Men (V)
Soccer Men (Green)
Soccer Men (Golod)
Tennis Women (V)
Tennis Women (JV)
Volleyball (V)
Volleyball (Green)
Volleyball (Gold)
Vaccination Status
*
Vaccinated (2 shots)
Booster
Unvaccinated
When were you last on campus?
-
Month
-
Day
Year
Date
Which class periods did you attend (select all that apply)?
1
2
3
4
5
6
7
8
Please list the names of any Gibbons close contacts you had between when your symptoms began and the 48 hours prior.
Close contact: Someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before symptoms began
Test Site
CGHS
Off-site
Back
Next
Date Test was taken.
*
-
Month
-
Day
Year
Date
Full name of parent/guardian submitting test results (if applicable)
First Name
Last Name
Email Address of person submitting test results.
*
example@example.com
Phone Number of person submitting test results
*
Please enter a valid phone number.
Format: (000) 000-0000.
Test Result
Please Select
Positive
Negative
Back
Next
Submit
Should be Empty: