GISD STAFF Confirmed Positive COVID-19

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Staff,

Please complete the form if you have tested positive for COVID-19 or have been diagnosed by a healthcare provider. Once completed, you will be notified of a return date.

ALL INFORMATION IS CONFIDENTIAL AND IS SHARED ONLY ON A NEED-TO-KNOW BASIS.

Padres,

Por favor complete el formulario si ha dado positivo en la prueba de COVID-19 o ha sido diagnosticado por un proveedor de atención médica. Una vez completado, se le notificará una fecha de regreso.

TODA LA INFORMACIÓN ES CONFIDENCIAL Y SE COMPARTA SÓLO EN CASO DE NECESIDAD DE CONOCERLO.

Email *

First Name (Primer nombre): *

Last Name (Apellido): *

Your Date of Birth (Fecha de nacimiento) *

YYYY

Address (Dirección) *

Phone Number (Número de teléfono)

Job Title (Título profesional) *

Campus (Instalaciones)

How were you diagnosed? (¿Cómo te diagnosticaron?) *

Where were you tested? (¿Dónde se evaluó al estudiante?) *

Family Doctor

CVS/Walgreens

At Home COVID Test

Midland Memorial Hospital

Urgent Care

Other:

When did you get tested or diagnosed? (¿Cuándo se evaluó a su estudiante?) *

YYYY

When were you last on campus? (¿Cuándo fue la última vez que estuvo en el campus?) *

YYYY

Do you have symptoms? (¿Tiene síntomas?) *

Yes

When did symptoms begin? (¿Cuándo comenzaron los síntomas?) *

YYYY

Please select all symptoms that apply (Seleccione todos los síntomas que correspondan): *

I DO NOT HAVE SYMPTOMS

COUGH

FEVER OR CHILLS

SHORTNESS OF BREATH OR DIFFICULTY BREATHING

FATIGUE OR EXTREME TIREDNESS

MUSCLE OR BODY ACHES

HEADACHE

NEW LOSS OF TASTE OR SMELL

SORE THROAT

CONGESTION OR RUNNY NOSE

NAUSEA OR VOMITING

DIARRHEA

Required

Do you have students or household members in GISD? (¿Tiene estudiantes o miembros del hogar en GISD?) *

YES (please list names in the following question)

Please list the names of students or household members in GISD and what campus they attend. (Indique los nombres de los estudiantes o miembros del hogar en GISD y a qué campus asisten.)

Please send any documentation including doctors notes or test results to gisdnurse@greenwood.esc18.net. (Envíe cualquier documentación, incluidas las notas de los médicos para los resultados de las pruebas, a gisdnurse@greenwood.esc18.net)

A copy of your responses will be emailed to the address you provided.

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