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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)

Have you been diagnosed with COVID-19, have you been in close contact with an individual with COVID-19*?
* "Close contact" means an individual who was within 6 feet of a confirmed or probable COVID-19 case for a cumulative total of 15 minutes or more in a 24-hour period during the time they were contagious. Individuals are contagious 2 days prior to having symptoms or two days prior to being diagnosed, if they are asymptomatic.
  

Date Tested? (mm/dd/yyyy)
Date Diagnosed? (mm/dd/yyyy)
Name of Lab?
Location of Lab?

Were you in close contact with an individual with COVID-19 in District 202 school, athletics, or activities?
  


Do you know the name of the diagnosed individual (if unsure, leave blank)?



Did you already receive a quarantine letter from the district?
  




Date you were in close contact with the individual with COVID-19? (mm/dd/yyyy)

Do you live with the individual(s) diagnosed with COVID-19?
  
Is there more than one person living in the same household as you who has been diagnosed with COVID-19 or is symptomatic for COVID-19?
  


Are all individuals that tested positive for COVID able to isolate (stay in a specific "sick room" or area and use a separate bathroom, if available)?
  


Has you tested positive on a lab-based COVID-19 test in the last 90 days?
  



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?