Bell County Public Health District
COVID-19 Reporting Form
Name of the School and School District:
Reporter Phone Number
Please enter a valid phone number.
Student or Staff?
Case Full Name
If a student, what is the parent/guardian's name?
Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
Does this person have symptoms? If so, please specify:
Has this person been instructed to self-isolate?
Is there any other information that we need right away?
If you have a copy of a laboratory confirmation please upload that here.
Drag and drop files here
Choose a file
Who are the known contacts within the school for this individual? Please provide names and phone numbers if possible.
If you do not have a lab report where was this person tested?
Should be Empty: