COVID-19 Health Services Online Reporting Form
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CISD Covid-19 Employee Reporting Form
1.
Employee’s Full Name/Nombre completo del empleado?
*
2.
What is your phone number/¿Cuál es tu número de teléfono?
*
3.
What is your email address/Cuál es tu dirección de correo electrónico?
*
4.
What is the nature of this report/Cuál es la naturaleza de este informe?
*
--Please Select--
Confirmed positive for COVID-19/Confirmado positivo para COVID-19
Potential positive for COVID-19/Potencial positivo para COVID-19
Notification of self-quarantine/Notificación de auto cuarentena
Notification of medical quarantine/ Notificación de cuarentena médica
Other/Otro
5.
If you selected “other” please explain here/ Si seleccionó "otro", explique aquí
6.
What campus are you assigned to/A qué campus te asignan?
*
--Please Select--
Virtual/online
Administration Building
Transportation Center
Maintenance & Operations
Drane Learning Center / Child Nutrition
Carroll Elementary
Bowie Elementary
Fannin Elementary
Navarro Elementary
Sam Houston Elementary
Collins Intermediate
Corsicana Middle School
Corsicana High School
7.
If you are positive, when was your last day on campus? / Si es positivo, ¿cuándo fue su último día en el campus?
mm/dd/yyyy
8.
Have you been vaccinated?
--None--
Yes
No
9.
If exposed, what is the date of exposure?
mm/dd/yyyy
10.
If employee is positive, what is the date of first symptom?
mm/dd/yyyy
11.
What is the date of the test?
mm/dd/yyyy
12.
Was test a rapid test or PCR?
13.
Where was the test taken?