SY22-23 - COVID-19 Off Site Exposure Survey

Submitter Information
This section collects information for the person submitting this form. If you are not the positive patient, please do not fill in the patient's information here. There is space for the patient's information on the following page.
Submitter Name:*

First NameLast Name
Submitter Email:*
example@example.com
Phone Number*
Please enter a valid phone number.
Who has been exposed to COVID-19?*

I was exposed (I am reporting my own exposure)My child was exposedOther
Where did exposure take place?*

Someone in the household tested positiveExposure took place outside of Bank Street, but it wasn't with someone in the same household
Is the person able to separate from the positive person in their household?*

YesNoOther

Exposure Information
Name of person exposed:*

First NameLast Name
Bank Street program/team:*
Role at Bank Street:*

StudentTeacher/Faculty or Classroom StaffNon-Classroom StaffOther
School for Children Grade:*
School for Children Classroom:*
Family Center Classroom:*
Head Start Classroom:*
Liberty LEADS Section: **ADD SECTIONS***
Days since exposure?
Today's Date

MonthDayYear
Date
When were you/your child last exposed? *

MonthDayYear
Would you like a follow up email from our health team? You will receive an automatic email once you submit, but you can select "yes" for additional support:*

YesNo
If you have any additional notes, please use the space below:
Recommended mask end date [hide]

MonthDayYear
Date
Note for exposure
Recommended PCR Testing Date: [hide]

MonthDayYear
Date
2nd Recommended PCR Testing Date: [hide]

MonthDayYear
Date
email pronoun [hide]
Follow Up?
Should be Empty:

Off-Site Exposure to COVID-19