COVID-19 Illness / Close Contact Intake Form

VCS employees and parents, please use this form: A) For EVERY incident of COVID-19 related symptoms (even if DARCY has been completed for the day) B) To notify the school of a close contact to a confirmed COVID-19 case.

Created By Full Name*

Created By Email Address*

Are you reporting an Illness or Close Contact?*

You may choose both (if applicable)

Select

Who has symptoms of COVID-19 or contact to a case?*

Select or enter value

Full Name*

(Individual with symptoms or contact)

Student Name*

School / Campus*

Select or enter value

Grade*

Select or enter value

Cohort/Class # or Work Location

Is this a VCS STUDENT ATHLETE?

Select

Cold or flu like symptoms?*

Are you or the individual you are screening experiencing cold or flu-like symptoms at this time (that cannot be explained by another reason)?

Yes

Symptoms (Select all that apply)*

Select or enter value

Temperature Reading

Non-Contact

Initial date of symptoms or possible exposure?*

Recent travel or known exposure*

Select or enter value

Travel or contact details*

If you answered 'yes' to the above question, please explain where and when you have traveled and if you believe you have been in contact with someone who has tested positive for COVID-19.

Diagnosed with COVID-19 within the last 10 days?*

Select

COVID test collection date

COVID Test Results Date*

Last day on campus YYYY-MM-DD

Upload Positive Test Results Here (if applicable)

Drag and drop files here or

Response

Response*

Please note the response to this illness

Select or enter value

Send me a copy of my responses

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