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IHSCA Student COVID-19 Self Report Form

This form should only be completed by students that have been diagnosed with COVID-19 by a medical professional.

Este formulario solo debe ser completado por estudiantes que hayan sido diagnosticadas con COVID-19 por un profesional médico.

Student First Name / Primer Nombre del Estudiante*

Answer Required

Student Last Name / Apellido del Estudiante*

Answer Required

Date of Birth / Fecha de Nacimiento*

Answer Required

Parent - Guardian Name / Nombre del Padre - Guardian*

Answer Required

Parent - Guardian Email / Correo Electronico del Padre - Guardian*

Answer Required

Parent - Guardian Phone Number / Numero Telefono del Padre - Guardian*

Answer Required

Have you tested positive for COVID - 19 / Ha dado positivo en COVID - 19*

Answer Required

Yes / Si

To the best of your knowledge, when did you first experience symptoms of COVID-19, such as fever, cough, and shortness of breath? / Cuándo experimentó por primera vez los síntomas del COVID-19, como fiebre, tos y dificultad para respirar?*

Answer Required

What date were you tested? / En que fecha te hicieron la prueba?*

Answer Required

What date did you receive your results? / En qué fecha recibió sus resultados?*

Answer Required

To the best of your knowledge, what was the last date you were present at IHSCA? / A su leal saber y entender, cuál fue la última fecha en la que estuvo presente en IHSCA?*

Answer Required