COVID-19 Case Reporting Form

COVID-19 Case Reporting Form
I am reporting a confirmed COVID-19 case for:*

MyselfPVA StudentPVA Staff MemberPVA Visitor
Sex (select one)*

MaleFemale
Name of Individual with COVID-19 *

First NameLast Name
Parent/Guardian/Caretaker Name*

First NameLast Name
Ethnicity (select one)*

Hispanic/LatinoNot-Hispanic/Latino
Race (select all that apply)*

African-American/BlackAmerican Indian/Alaska NativeAsianCaucasian/WhiteNative Hawaiian/Other Pacific Islander
Date of Birth*

MonthDayYear
Date
Age*
Grade*

3rd4th5th6th7th8th9th10th11th12th
Is COVID-19 confirmed individual fully vaccinated? Per the CDC: In general, people are considered fully vaccinated: 2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine. If an individual does not meet requirements, regardless of your age, individual is NOT fully vaccinated.*

YesNo
Lab confirmed positive date*

MonthDayYear
Lab Confirmed Date
Last date infected individual was on campus*

MonthDayYear
Last Date on Campus
Onset of symptoms (i.e. date of first symptom)*

MonthDayYear
Onset of Symptoms Date
Participation in school sports and/or extracurricular activities?*

YesNoUnknown
List school sports and/or extracurricular activities*
List all areas in the campus the infected individual visited.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email (if the case is a student, provide parent/guardian/caretaker email address)*
example@example.com
Close Contacts

Per the Centers for Disease Control and Prevention (CDC)
Close Contact through Proximity and Duration of Exposure: Someone who was within 6 feet of an infected person (laboratory-confirmed or a clinically compatible illness) for a cumulative total of 15 minutes or more over a 24-hour period (for example, three individual 5-minute exposures for a total of 15 minutes). An infected person can spread SARS-CoV-2 starting from 2 days before they have any symptoms (or, for asymptomatic patients, 2 days before the positive specimen collection date), until they meet criteria for discontinuing home isolation.

Exception: In the K–12 indoor classroom setting, the close contact definition excludes students who were within 3 to 6 feet of an infected student(laboratory-confirmed or a clinically compatible illness) if both the infected student and the exposed student(s) correctly and consistently wore well-fitting masks the entire time.

This exception does not apply to teachers, staff, or other adults in the indoor classroom setting.

https://www.cdc.gov/coronavirus/2019-nCoV/index.html
Any Close Contacts to Report?*

YesNoUnknown
Enter PVA close contact(s) below. Enter as much information as possible. Click + to add more.*
Attachment(s) *

Please attach lab confirmed results and vaccination card if applicable.
Cancelof
The Pro-Vision Academy (PVA) is required to notify state and local health departments of all known COVID-19 confirmed cases. PVA will notify any identified close contacts per the CDC's close contact definition. PVA will also notify the local health department of any identified close contacts.
Should be Empty:

COVID-19 Case Reporting Form

Close Contacts