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COVID-19 Reporting Form
Please submit this form ONLY if you as a staff person or a student of Grand Ledge Public School has tested POSITIVE for COVID-19.
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* Indicates required question
Student or Staff
*
Student
Staff
Name of School
*
District Location where COVID-19 positive person was last onsite
Grand Ledge High School
Beagle Middle School
Hayes Intermediate School
Delta Center Elementary
Holbrook Elementary
Wacousta Elementary
Willow Ridge Elementary
Delta Mills Early Childhood
Neff Early Childhood
Other:
First Name
*
COVID-19 Positive Person's First Name
Your answer
Last Name
*
COVID-19 Positive Person's Last Name
Your answer
Birthdate
*
COVID-19 Positive Person's Birthdate
MM
/
DD
/
YYYY
County of Residence
*
COVID-19 Positive Person's County of Residence
Your answer
Email Address
*
Staff or Parent/Guardian contact email address
Your answer
Phone Number
*
Staff or Parent/Guardian contact phone number
Your answer
Date Tested
*
MM
/
DD
/
YYYY
Test Location
*
Your answer
Date staff or student was notified of test result
*
MM
/
DD
/
YYYY
Date staff or student last worked/was in school
*
MM
/
DD
/
YYYY
Symptom Onset
First date that symptoms started
MM
/
DD
/
YYYY
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