Monroe County, NY COVID-19 School Reporting Form

School District

School Name/Building

School Contact First Name

School Contact Last Name

Contact Email

School Phone #

Type Student Faculty/Teacher Staff (non-teacher) Volunteer/Visitor

First Name

Last Name

Date of Birth

Parent First Name (if student)

Parent Last Name (if student)

Parent/Staff Phone #

Symptoms Onset Date

Temperature

Loss of Taste Loss of Smell

Description of Symptoms

If known, please state reason for no test and/or health care provider evaluation