We encourage you to provide your name and birthdate (or the name/birthdate of the person you are reporting for) so that we can ensure that there is no duplication in reporting and that we can confirm the accuracy of school work history. We will keep all information confidential according to HIPAA requirements. Also, you have the option to remain anonymous.

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* 1. Name (optional)

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* 2. Birthdate (optional)

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* 3. Today’s date

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* 4. Years of Elmira HS (formerly Southside HS) employment

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* 5. Job title and duties

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* 6. Portion of school (floor/wing) where you spent most of your time

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* 7. On average, how many hours per week did you spend in the school; (if a wide range due to extra-curricular activities, please indicate the range)

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* 8. Health concerns/illnesses and dates/ages for yourself

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* 9. Health concerns/illnesses and dates/ages for your children or other family member for whom you are reporting. 

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* 10. Phone Number:

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* 11. Times Best Reached:

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