COVID Data Entry Form

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Please complete the following form to report suspected or confirmed cases of COVID 19.

Today's Date *

YYYY

Date of first student absence related to COVID (Type NA if student has not missed school yet) *

Student Last Name, First Name *

Student ID without the "S" *

Grade *

6th

7th

8th

Is your student involved in Extra Curricular Activities? If so please list, if not please type NA. *

Your Name & Relationship to Student: Last Name, First Name, Relationship (mother, father, grandparent, guardian, etc.) *

Your Phone Number *

Your Email *

Has your student had a known exposure to COVID 19 in the last 2-weeks? Type Yes or No, If yes also type in the date of last exposure to the positive individual *

What type exposure was your student exposed to? *

Community

Household

School

Unknown

Student Symptoms (Please type NA if student is not symptomatic) *

Start Date for Symptoms (Please type NA if student does not have symptoms) *

Last Date on Campus or at NISD Event *

YYYY

Vaccinated Status *

Vaccinated Plus Booster

Vaccinated without Booster

One vaccination shot awaiting second shot

Not vaccinated

COVID Test Date (Type NA if student has not been tested) *

COVID Test Results *

Positive - my student has COVID 19

Negative - my student does not have COVID 19

Not Tested

Pending

Type of COVID Test *

Rapid Test

PCR Test

Home Test

I know and understand that I need to email all test results to Garcia Nurse at kathryn.cruz@nisd.net *

Yes

I know and understand that I need to email all doctor's notes and medical documentation for this case to Garcia Nurse at kathryn.cruz@nisd.net & Attendance Secretary erika.castillo@nisd.net *

Yes

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