subject_line
Positive COVID-19 Report Form
Name of Positive Individual:
*
Student or Staff Member?
*
Student
Staff Member
Parent/Guardian Name if student:
*
Contact Number:
*
Email Address:
*
Student Grade:
*
PreSchool
K
1
2
3
4
5
6
7
8
9
10
11
12
Staff Member Position
(include grade or subject/s if you are a teacher):
*
School or Work Site:
*
Cielo Azul Elem.
Colinas Del Norte Elem
Enchanted Hills Elem
Ernest Stapleton Elem
Joe Harris Elementary
Maggie Cordova Elem
Martin Luther King Jr. Elem
Puesta Del Sol Elem
Rio Rancho Elem
Sandia Vista Elem
Vista Grande Elem
Eagle Ridge MS
Lincoln MS
Mountain View MS
Rio Rancho MS
Cleveland HS
Rio Rancho HS
Independence HS
Rio Rancho Cyber Academy
Sandia Vista Montessori
District Office or Other RRPS Facility
Does the student
ride the bus?
*
Yes
No
Bus
number:
*
Other before or after-school activities (sports, SAFE, etc), please list:
Date Tested:
*
+
Date Notified of Positive Result:
*
+
Reason for Test:
*
1. Staff surveillance Testing
2. Identified as a close contact
3. Symptomatic
4. Other
4. Other
If due to being symptomatic,
what day did symptoms begin?
*
+
Last day at school
or work site:
*
+
form admin
only - test
y
n
Thank you for completing this form. Someone will be in contact soon.