Student - Week 5 Covid 19 Reporting Form

1

Student Name* This field is required.Nombre del estudiante

Last Name

First Name

2

Student Email* This field is required.Correo electrónico del estudiante

example@example.com

3

Student Phone Number* This field is required.Número de teléfono del estudiante

Please enter a valid phone number.

4

Parent Name* This field is required.Nombre del padre

First Name

Last Name

5

Parent Email* This field is required.Correo electrónico de los padres

example@example.com

6

Parent Phone Number* This field is required.Número de teléfono de los padres

Please enter a valid phone number.

7

Symptoms* This field is required.Do you have any of the following symptoms? Fever or chills Cough Shortness of breath/difficulty breathing New loss of taste or smell Fatigue / tiredness Runny or stuffy nose Muscle or body aches Headache Sore throat Nausea or vomiting Diarrhea Feeling generally unwell

YESNO

8

Close Contact* This field is required.Since your last day in residence in Upward Bound, have you been in close contact with someone who recently tested positive for COVID-19, for a total of 15 minutes or more over a 24-hour period?

YESNO

9

Covid-19 Test Result* This field is required.Resultado de la prueba COVID-19

Positive (Positivo)

Negative (Negativo)

Inconclusive / Invalid Result (Resultados no válido)

I am ineligible or not required to test (No soy elegible o no estoy obligado a realizar la prueba

10

Date Test was Taken* This field is required. fecha en que se tomó la prueba

Date

11

Upload a picture of your COVID-19 Test Results* This field is required.Picture of Covid Test

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

12

I have read and followed the rapid antigen test directions.* This field is required.

AGREEDISAGREE

13

The COVID-19 test listed on this form was taken by my student on July 15th, 2023.* This field is required.

AGREEDISAGREE

14

Per LA County Guidelines, my student is ineligible / not required to test. My student tested COVID-19 positive within the past 90 days on * (Please provide month, date, and year).

15

You are seeing this message because you indicated that your student:

is exhibiting symptoms consistent with COVID
had close contact withs someone who tested positive for COVID-19
tested positive for COVID-19
received an inconclusive/invalid test result.

PLEASE DO NOT COME TO CAMPUS.

The Upward Bound Covid/Health coordinator will contact you soon.

Please sign on the the next page.

16

Parent Signature* This field is required.This signature indicates that all information added onto this form is accurate and up-to-date.

Clear