Bell County Public Health District
COVID-19 Reporting Form
Reporter Name
*
First Name
Last Name
Name of the School and School District:
*
Reporter Phone Number
*
Please enter a valid phone number.
Reporter's Email
*
example@example.com
Student or Staff?
*
Please Select
Student
Staff
Case Full Name
*
First Name
Last Name
If a student, what is the parent/guardian's name?
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Gender
*
Please Select
Male
Female
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.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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?
Submit
Should be Empty: