Health Department Reporting Form
PPLC Student Information
1260 Driver Road, Marriottsville, MD 21104 - Phone: (410) 442-1440 - E-mail: info@peterpanlearningcenter.com
Child's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Onset date of symptoms
*
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Month
-
Day
Year
Test Date
*
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Month
-
Day
Year
Type of test (Rapid, PCR, home test)
*
Vaccination Status
*
Last day in the facility
*
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Month
-
Day
Year
Phone Number
*
Name and Relation to the patient
*
Verify that you are a human
Submit
Should be Empty: