COVID-19 Case Reporting Form

COVID-19 Case Reporting Form

Report Type*

Positive Case

Contact to a Positive Case (SLC District Only)

School Information

Please select your school name from the dropdown (Canyons):*

Select

Please select your school name from the dropdown (Charter):*

Select

Please select your school name from the dropdown (Granite):*

Select

Please select your school name from the dropdown (Jordan):*

Select

Please select your school name from the dropdown (Murray):*

Select

Please select your school name from the dropdown (Private):*

Select or enter value

Please select your school name from the dropdown (Salt Lake):*

Select

Please enter your school name (Child Care):*

REPORTED BY*

Name of individual reporting

REPORTED BY PHONE NUMBER*

Phone

REPORTED BY EMAIL*

Student / Teacher / Staff Information

CASE TYPE*

Student

Teacher

Staff

GRADE*

Select

GRADE*

Select

OCCUPATION*

FIRST NAME*

LAST NAME*

DATE OF BIRTH*

STUDENT / STAFF ID NUMBER*

If Student/Employee ID is not available, please enter 0.

CLASS SCHEDULE*

Please enter the name(s) of all teacher(s) for this student.

Enter N/A for Staff/Teacher cases.

PARENT NAME*

Please provide first and last name of the student's parent.

EMAIL ADDRESS

Student's parent email OR Teacher/Staff Email

PHONE NUMBER*

Student's parent OR Teacher / Staff Phone number

Phone

MOST LIKELY SOURCE OF EXPOSURE*

School exposure

Social exposure

Household exposure

Unknown

LAST DAY EXPOSED TO POSITIVE CASE

LAST DAY AT SCHOOL*

DATE PERSON WAS TESTED*

WAS AN AT HOME TEST USED?*

Yes

Unknown

IS THE INDIVIDUAL SYMPTOMATIC?*

According to the CDC, people with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness