Staff Online Contact Tracing Form

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:

Aux Sable MS	Eichelberger ES	Liberty ES	Ridge ES
Bonnie McBeth LC	Freedom ES	Lincoln ES	River View ES
Central ES	Grand Prairie ES	Meadow View ES	Thomas Jefferson ES
Charles Reed ES	Heritage Grove MS	Plainfield Academy	Timber Ridge MS
Creekside ES	Indian Trail MS	Plainfield Central HS	Walker's Grove ES
Crystal Lawns ES	Ira Jones MS	Plainfield East HS	Wallin Oaks ES
Drauden Point MS	John F Kennedy MS	Plainfield North HS	Wesmere ES
Eagle Pointe ES	Lakewood Falls ES	Plainfield South HS	Ina Brixy
District Admin	OMT	Technology

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?

YES NO

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)

YES NO

Have you received a COVID-19 booster?

YES NO