COVID Exposure Form - Westside Christian High School

COVIDPositive / Covid Exposure Notification Form:

Please complete this form to provide notification to WCHS of a person who has been on campus who:

Is feeling ill with COVID Symptoms
Been exposed to COVID
Tested positive for COVID

This information will be kept confidential.

If you have more than one person in your household that you need to notify WCHS about, please submit a different form for each individual.

Today's Date *

Current Time *

First and last name of the person who is COVID + / been exposed to COVID: *

This person is a: *

This person (check all that apply):

tested positive for COVID in the last 14 days was informed by a medical or health professional that they are presumed positive for COVID is feeling ill with COVID symptoms has had direct contact with someone who has tested positive for COVID

What is the last date that any of the previous statements were true for this person (i.e. Last Date of Exposure):

Date of last exposure:

Date of COVID test:

If this person has not had a COVID test, has a COVID test been scheduled or is in process?

If this person has symptoms, what symptoms are they experiencing and what day was the first symptom?

What was the last date that this person was on the WCHS campus:

What was the last time this person was on the WCHS campus:

Name of the person completing this notification form:

Best Phone Contact Number *

Email Address of person completing this form *

Short Answer Label

Enter Your Email Address: *