COVID-19 – ANS Forms

COVID-19 Symptoms Report

This form is for symptomatic persons (Student, Staff or Teachers) who develop any COVID-19-related symptoms, have a positive test or were in closed contact of a positive person or suspect case.

Please stay Home if you have any symptoms or are in close contact.

This information is only for contact tracing purposes and is confidential and won’t be shared.

COVID-19 Report

General Information
Name*
First Middle Last Suffix
Member Type*
- Student
- Faculty
- Staff
Grade Level
Area
Phone Number*

Please enter numbers only. No dashes/hyphens allowed.
Email*
Name of Person Filling the Form*
First Last
Reason for Filling Report*
- Symptoms
- Close Contact
- Suspicious Case
- Positive Case
Date Symptoms Started
Date of Test
Please mention the Symptoms of the Affected Case*
Close Contact Information
Date of Close Contact
Date your Close Contact's Symptoms Started
Does your Close Contact have a test
- Yes
- No
Close Contact Test Date
When was your last date at school?
Additional Comments

COVID-19 Symptoms Report

COVID-19 Report

General Information

Close Contact Information