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Staff Online Contact Tracing Form



First Name
Last Name
Date of Birth (mm/dd/yyyy):
Email Address
Primary Building where you work

Additional buildings where you may work:
 
Position/Title:
Main Contact Phone #
Home Address:
City:
State:
Zip:
County (Will, DuPage, Grundy, etc.):


What was your last day of attendance in a District building? (mm/dd/yyyy)


Date of COVID-19 Test? (mm/dd/yyyy)
Date Diagnosed? (mm/dd/yyyy)
Name of Lab?
Location of Lab?



Have you ever had symptoms?
  
If yes, what was the first date of symptoms? (mm/dd/yyyy)


Are you fully Vaccinated for COVID-19? (14 days after a single dose vaccine or 14 days after second shot of a two dose vaccine)
  


Have you received a COVID-19 booster?