COVID-19 Reporting Form

Please complete the form below with information for the affected individual. Required fields marked with an asterisk *

First Name*

Answer Required

Last Name*

Answer Required

Date of Birth*

Answer Required

Phone Number*

Number Required

Email Address *

Answer Required

Campus you attend for work or study*

Answer Required

Downtown Campus

East Campus

West Campus

If you are reporting on behalf of another person, please place your own name and contact information here.

Answer Required

How do you know COVID-19 is present? (Check all that apply)*

Answer Required

Lab-Confirmed Case (Positive COVID-19 test)

Clinical Diagnosis (Doctor's diagnosis)

Probable Case (Meets symptom criteria and have had contact with someone confirmed to have COVID-19)

Exposure to someone confirmed to have COVID-19

If your case of COVID-19 is lab-confirmed, please list the date that your COVID-19 test was done.

Answer Required

What was your process for confirming COVID-19? (Check all that apply)*

Answer Required

Felt ill and went to the doctor

Contact tracing/exposure to COVID-19

Other

Exposure information: In the 14 days prior to your illness or diagnosis, have you had any of the following exposures? (check all that apply)*

Answer Required

Workplace

School

Contact with an individual known to have COVID-19

None of these exposures

If you were exposed to an individual known to have COVID-19, please tell us what type of contact. (Check all that apply)

Answer Required

Household contact

Community-associated contact (i.e., at work, at school, at a public event)

Healthcare related contact (i.e., a patient or visitor in a healthcare system)

Have you had symptoms related to COVID-19? (Check all that apply)*

Answer Required

Symptomatic

Asymptomatic

Unknown

If your case is symptomatic, what was the first date you noticed symptoms?

Answer Required

Have you reported physically to any of the Invictus High School Campus locations in the last 14 days? (Check all that apply)*

Answer Required

Downtown Campus

East Campus

West Campus

I have not physically reported to any of the Invictus High School Campus locations in the last 14 days

If you have physically reported to any of the Invictus High School campuses in the last 14 days, please indicate the campus location(s), individuals you interacted with, and the locations on campus you visited (i.e., men's restroom, English classroom, Director's office) in as much detail as possible.

Answer Required

Have you been diagnosed with COVID-19 at any time before this (lab or doctor confirmed case)?*

Answer Required

Yes

Have you been vaccinated for COVID-19 (You may be asked to provide proof of vaccination)?*

Answer Required

Yes (First Dose Only)

Yes (First and Second Dose)

Yes (First and Second Dose and a booster vaccine dose)

Please provide additional information that may be of interest to the COVID-19 Coordinator.

Answer Required

Please fix the highlighted areas below before submitting.

COVID-19 Reporting Form