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:
Main Contact Phone #
Home Address:
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?