COVID Notification Form

Fill out the form below.


Date:
*
 

Name of School:
*
 

Name of Person Submitting This Form:
*
 

Affiliation with School of COVID-19 Individual:
*
(i.e. Student, Parent, Volunteer, Staff, Faculty, etc.)
 

Other Details:
*
(Grade—if student; Grade/Subject Taught—if teacher; Other Pertinent Information.)
 

Name of Local Health Department Where COVID-19 Positive Individual’s Information Was Sent:
*
 

* = Required field


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