COVID-19 Reporting Form General Info Reporting Form Dashboard Decision Tree Response Protocol Operating Modalities 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. Why are you submitting a form?*Please indicate why you are completing this form.First time reportUpdate previous reportRequest to return to campusWhich role best describes you?*Please select one of the following.Student or ParentFaculty/StaffWhich 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?*Examples might include COVID-19 test results or physician documentationYesNoHave you had a COVID-19 Test?*YesNoPerson Completing Form*Please provide your name, email, and phone number. First Last Email Address* 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-K3Pre-K4Junior KindergartenKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Student Date of Birth* Date Format: MM slash DD slash YYYY Faculty/Staff Division*Please indicate within which division you work.Non-Teaching/AdministrativeLower SchoolMiddle SchoolUpper SchoolWhat date did symptoms first appear?*Please select the date in which COVID-19 symptoms first started. Date Format: MM slash DD slash YYYY Please describe symptoms*Do you believe symptoms are non-COVID related?non-COVID related could include season allergies, common cold, etc.YesNoDate of COVID-19 Testing* Date Format: MM slash DD slash YYYY COVID-19 Test Results*Please indicate the results of the test.PositiveNegativeResults PendingDate Last on Campus*Please select the date in which student/staff was last on LCA's campus. Date Format: 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. Date Format: 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 Persons of Close Contact*Please list the names of any LCA student, faculty, or staff with whom you were in close contact starting from two days before illness onset or two days prior to date when your were tested (not when you received your results).Additional InformationPlease 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: Completed the required quarantine Be COVID-symptom free 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?*NoYesDocumentation Upload*Examples might include COVID-19 test results or physician documentation Drop files here or Documentation UploadExamples might include COVID-19 test results or physician documentationCommunication 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
