BCA Bayou Community Academy
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COVID-19 Reporting Form
Name
*
First
Last
Email
*
Phone
*
I am a:
*
Student
Professional
Grade Level
*
Homeroom
*
I am reporting:
*
Positive COVID-19 test
Negative COVID-19 test
Close contact with someone with COVID-19
What is the last day you attended BCA in person?
*
MM slash DD slash YYYY
If you've experienced symptoms, please list:
Positive Test Results
Have you been tested for COVID-19?
YES
NO
If tested, what were the results?
POSITIVE
NEGATIVE
Date Tested:
MM slash DD slash YYYY
Date results were received:
MM slash DD slash YYYY
Date symptoms began:
MM slash DD slash YYYY
Exposure/Close Contact
For COVID-19, a close contact is defined as anyone who was within 6 feet of an infected person for at least 15 minutes starting from 48 hours before the person began feeling sick until the time the patient was isolated.
Date of exposure/close contact with infected person:
MM slash DD slash YYYY
If known, where and how were you exposed (had close contact as defined above)?
Date your symptoms started (if any):
MM slash DD slash YYYY
Please list individuals who have been in close contact (defined above) with you since two days prior to the onset of symptoms or two days prior to a positive test.
Please provide an emergency contact. Include name, relation, and contact phone number below:
Consent
*
I acknowledge my data is shared only with appropriate personnel.
Δ