Epidemiology, Community Assessment and Research Initiatives
201 Second St., Suite 1100, Macon, GA 31201
nchd.epi@dph.ga.gov, Fax: 478-751-6074
COVID-19 CASE REPORT FORM (School / Childcare)
Na
me of Student/Employee: _________________________________________ DOB: _______________
Hom
e Address: _______________________________________________________________________________
City: __________________________ State: _________________ Zip Code: ______________
Gender: □Male □Female Race: ______________ __ □Hispanic □Non-Hispanic Interpreter? □Yes □No
Parent(s)/ Guardian: _________________________ ___ Home phone#: ________ _______
Cell or work phone#: ____________ _______ E-mail _____ ___________________
School: ____________________________ _____Teacher/Grade: _______________________________
Extracurricular Team(s)/School Activities: _ _____________________________________
Bus
Rider?
□Yes □No Does the student/employee change classrooms during day? □Yes □No
CO
VID-19 Test?
□Yes □No □ Unknown Lab result provided to school nurse? □Yes □No
Lab Date: _______
______ Testing Facility: ________________________________________________
Sibling or family member who attends/works at the school? □Yes □No (If yes, please include on line list on pg. 2-3)
H
ospitalized:
□Yes □No □Unknown Facility: ___________________________ Date of Admission: _________________
IF SYMPTOMATIC: Symptom onset date: ___/____/____ □ Unknown
• Inf
ectious period starts 2 days before symptom onset Infectious period onset date: ___/____/____
• Isolation period: 10 days starting from symptom onset AND 24 hours fever-free with improvement of symptoms
IF ASYMPTOMATIC: Lab collection date: ___/____/____ □ Unknown
• Inf
ectious period starts 2 days before lab collection date Infectious period onset date: ___/____/____
• Isolation period: 10 days starting from positive lab date unless symptoms develop, then use criteria for symptomatic cases
Cl
ose contacts of the positive Student/Employee identified?
□ Yes □No (If Yes, please complete line list on pages 2-3)
• Close contact: Less than 6 feet for more than 15 minutes during the positive student/employee’s infectious period (this
time frame is cumulative)
• Quarantine period for close contacts of positive student/employee: 14 days from date of last exposure, regardless of
obtaining a negative test result during the 14 days
• DPH recommends that close contacts of positive students/employees wait 10 days from last date of exposure to be
tested, unless symptoms develop sooner.
Date(s) of school attendance OR participation in extracurricular activities during the infectious period
_______________________________________________________________________________________________________
