COVID Reporting Form

It is critical that students, faculty, and staff who have been potentially exposed to or tested positive for COVID-19 complete the below form to ensure that we can continue to provide the safest on-campus learning environment possible. This information will also assist LCA in partnership with public health officials to monitor the incidence of cases occurring within the LCA community. We are committed to ensuring that your submission remains confidential in accordance with applicable laws and will only be used to provide to ensure those who have been exposed are contacted.

Tap here to review LCA's COVID-19 Protocols.
Why are you submitting a form?*
Please indicate why you are completing this form.
- First time report
- Update previous report
- Request to return to campus
Which role best describes you?*
Please select one of the following options.
- Student or Parent
- Faculty or Staff
Is the student/staff member for whom the form is being completed fully vaccinated for covid?*
Please select one of the following options.
- Yes, vaccinated
- No, unvaccinated
- Prefer not to report
Which of the following best describe your situation?*
Please read the following statements carefully. Then select any that apply.
- LCA Student/Staff has tested positive for COVID-19 and is presenting symptoms
- LCA Student/Staff has tested positive for COVID-19 and is asymptomatic.
- LCA Student/Staff is presenting symptoms of COVID-19, but has NOT tested positive.
- LCA Student/Staff was a close contact with a lab-confirmed COVID-19 positive individual.
- A household member that does NOT work at or attend LCA has tested positive for COVID-19
Do you have documents to upload for the student/staff member for whom the form is being completed?*
Examples might include COVID-19 test results, physician documentation, or COVID-19 vaccine card (both sides if information is written on the back). Please note that individuals may be eligible for an earlier return to school with proof of vaccination.
- Yes
- No
Have you had a COVID-19 test?*
- Yes
- No
Person Completing Form*
Please provide your name, email, and phone number.
First Last
Email Address*
Phone Number*
Would you like to add a second point of contact (parent/guardian)?
Secondary Contact Information*
Please provide secondary contact name, email, and phone number.
First Last
Secondary Contact Email Address*
Secondary Contact Phone Number*
Student Name*
Please provide the name, grade, and date of birth for your student; a form will need to be submitted for each LCA student impacted.
First Last
Student Grade*
- Pre-K3
- Pre-K4
- Junior Kindergarten
- Kindergarten
- Grade 1
- Grade 2
- Grade 3
- Grade 4
- Grade 5
- Grade 6
- Grade 7
- Grade 8
- Grade 9
- Grade 10
- Grade 11
- Grade 12
Student Date of Birth*
MM slash DD slash YYYY
Faculty/Staff Division*
Please indicate within which division you work.
- Non-Teaching/Administrative
- Lower School
- Middle School
- Upper School
What date did symptoms first appear for the student/staff member?*
Please select the date in which COVID-19 symptoms first started.
MM slash DD slash YYYY
Please describe symptoms for the student/staff member.*
Do you believe symptoms are non-COVID related for the student/staff member?*
non-COVID related could include season allergies, common cold, etc.
- Yes
- No
Date of COVID-19 Testing*
Please indicate the date of the nasal PCR test for the student/staff member.
MM slash DD slash YYYY
COVID-19 Test Results*
Please indicate the results of the nasal PCR test for the student/staff member.
- Positive
- Negative
- Results Pending
Date Last on Campus*
Please select the date in which student/staff was last on LCA's campus.
MM slash DD slash YYYY
Date of Last Exposure*
Please enter the date of LCA student/staff's last known exposure to COVID+ household member. Exposure is defined as close contact of 6 feet or less for 15 minutes or more.
MM slash DD slash YYYY
LCA Persons of Close Contact

Close Contact is defined as:
- You were within 6 feet of someone who is COVID+ for a total of 15 minutes or more
- You provided direct care at home to someone who is COVID+
- You had direct physical contact with COVID+ person (hugged or kissed them)
- You shared eating or drinking utensils with COVID+ personA COVID+ person sneezed, coughed, or somehow got respiratory droplets on you
List of Household Close Contacts*
Please list the names of any LCA student, faculty, or staff within your household with whom you were in close contact starting from two days before illness onset or two days prior to date when you were tested (not when you received your results).
Additional Information
Please provide any additional information you believe will be helpful to our LCA Health Services team.
Students/staff requesting to return to campus must meet the following three requirements:
1. Completed the required quarantine
2. Be COVID-symptom free
3. Be fever-free for 24-hours without the use of fever-reducing medicine.
Has the student/staff member requesting to return to campus fulfilled the three requirements listed above?
- Yes
- No
Document Upload
Examples might include COVID-19 test results, physician documentation, or COVID-19 vaccine card (both sides if information is written on the back). Please note that individuals may be eligible for an earlier return to school with proof of vaccination.
Drop files here or

Max. file size: 100 MB, Max. files: 4.
Communication Acknowledgement*
By submitting this form, I agree to be contacted via email and phone by LCA Health Services concerning the information provided.
I agree to be contacted by LCA Health Services

Monday	8:00 AM - 4:00 PM
Tuesday	8:00 AM - 4:00 PM
Wednesday	8:00 AM - 4:00 PM
Thursday	8:00 AM - 4:00 PM
Friday	8:00 AM - 4:00 PM