COVID-19 Self Report

***If you are filling out this form in the PCS App, stop! Go to the bottom of your screen (if you are using an iPhone) and click on the box with an arrow icon (furthest to the right). Choose "Open in Safari" or "Open in Chrome and fill it out on a web browser. The Blackboard App is experiencing issues with uploads***

Home is the first point of the screening continuum. PCS will educate and support families on identifying the symptoms that indicate students and staff must stay at home. Families should self-report symptoms of illness, which could include fever, new-onset cough, etc.

Please only complete this form if you are reporting COVID symptoms, test results, or other COVID situations. If you have zero symptoms, zero exposure, and zero reasons to isolate, please do not complete this form.

Please complete this form as soon as symptoms are experienced. Results may be uploaded at a later date on this same form.

I am a PCS: *

School/Location *

Have you already submitted a form for this person and only need to upload test results, doctors' notes, etc.? *

Student First Name *

Student Last Name *

Grade Level *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Phone Number *

Parent/Guardian Email Address *

Employee First Name *

Employee Last Name *

Employee Email Address *

Symptoms may appear 2-14 days after exposure to the virus. Symptoms of illness to be reported: *

Date of Symptom Onset: * +

Have you been tested for COVID-19? *

Date of COVID-19 test * +

Did your test come back as positive or negative? *

Have you been in contact with anyone who has COVID-19 in the last two weeks? *

Does your child sit next to someone in school or on school transportation who recently tested positive? *

If you answered yes to your child sitting near someone who recently tested positive, please provide as many details as possible below. *

From the date of contact/exposure, how many days passed before you were tested? *

Have you had a fever in the last two weeks or since your last time on campus? *

Have any of the persons living in your household been around anyone with COVID-19 since your last time on campus or in the last two weeks? *

Results Upload

Was your test positive or negative? *

Please provide any other information that might be helpful, including but not limited to: extracurricular activities you are involved in (sports teams, band, clubs, organizations, etc.) or special activities/events you may have attended around other PCS students or staff. Please add details as to your last day on campus as well.

Has your child been on a school bus in the past week? *

Please provide further details in reference to your child on the school bus, including, but not limited to:
*Date of last bus ride
*Bus Number if available
*If they ride in the AM or PM
*Address they are picked up from or dropped off at *

Were you advised by the system lead nurse to isolate due to possible exposure? *