NURSE COVID-19 Report Form NURSE COVID-19 Report 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. Why are you submitting a form?*Please indicate why you are completing this form.Nurse SubmissionWhich role best describes the individual for whom you are submitting the form?*Please select one of the following.StudentStaffWhich of the following best describe the 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 documentationYesNoHas the individual had a COVID-19 Test?*YesNoStaff 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 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(Not required) 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*Are the symptoms 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.PositiveNegativeDate Last on Campus*Please select the date in which individual 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 Additional InformationPlease provide any additional information you believe will be helpful to our LCA Health Services team.Documentation Upload*Examples might include COVID-19 test results or physician documentation
