OAG COVID-19 Tracking Form
Confirmed or Suspected Case Information for Odyssey Academy Galveston
Name of Person Who Is Confirmed or Suspects COVID-19:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
Email:
*
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Sex:
*
Male
Female
Ethnicity:
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White (Hispanic or Latino)
White (Not Hispanic or Latino)
Which OA school do you belong to?
*
Please Select
OA-Bay Area
OA-Galveston
OA-Texas City
Are you an OA:
*
Student
Staff
What grade level are you in?
*
How old are you?
*
Who is your home room and/or 1st period teacher?
*
Do you switch classes?
*
Yes
No
Do you participate in any on-site before/after school activities?
*
Yes
No
Please list what before/after school activities you participate in:
*
What was the last day you were on campus?
*
-
Month
-
Day
Year
COVID-19 MEDICAL INFORMATION
What is your current status regarding COVID-19?
*
Confirmed that I have it
I suspect that I might have it
I have come in close contact with someone who has it
Does the close contact reside in the home with the person listed on the tracker?
*
Yes
No
What was the date the close contact was tested for COVID-19?
-
Month
-
Day
Year
Have you had symptoms of COVID-19?
*
Yes
No
What date did the symptoms start?
*
-
Month
-
Day
Year
Select all the symptoms you are having:
*
Fever
Chills
Rigors
Myalgia
Headache
Nausea or Vomiting
Diarrhea
Fatigue
Congestion or Runny Nose
Sore Throat
Shortness of Breath
Difficulty Breathing
New Olfactory Disorder
New Taste Disorder
Other
Have you been tested for COVID-19?
*
Yes
No
What kind of COVID-19 test did you have?
Rapid (Results in 15 mins)
PCR (Results in 48-72 hours)
What was the date of your COVID-19 test?
-
Month
-
Day
Year
What was the result of your COVID-19 test?
Positive
Negative
If you have your test result, you can upload it here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
VACCINE INFORMATION
.
Have you been vaccinated?
*
Yes
No
Which vaccine did you choose?
Pfizer
Moderna
Johnson & Johnson
Date of Dose #1:
-
Month
-
Day
Year
Date of Dose #2 (if applicable):
-
Month
-
Day
Year
Is there any other information that you think would be helpful for us to know?
Please verify that you are human:
*
Submit
Should be Empty: