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1. Today's Date (ex. Monday, January 3, 2022). (Required.)

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2. What is the student's name in the HISD system? (Required.)

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3. Please provide the first and last name of one parent/guardian of this student. (Required.)

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4. What is the parent's/guardian's email address? (Required.)

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5. What is the best phone number to reach the student's parent/guardian? (Required.)

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6. What is the student's full home address (ex. 13 Rio Dr., Houston, TX 77002)? (Required.)

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7. What county does the student reside in? (Required.)

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8. What is the student's grade? (Required.)

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9. What is the student's art area? (Required.)

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10. When was the student's last day on HSPVA campus? (Required.)

Date

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11. What type of COVID-19 case are you reporting on your student? (Required.)

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12. Please list all locations the student visited on their last day on campus and include two days prior to their last day on campus, list all classrooms, restrooms by floor, list where the student eats lunch and what common areas did the student use (ex. library). If the student has not been on campus recently due to school holidays put that in the comment box. (Required.)

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13. If you are reporting your student as a confirmed or presumed COVID-19 positive please list the names of any HSPVA students that have been exposed to your child (ex. who does your child eat lunch with). Exposure is defined at less than 6 feet for greater than 15 minutes with or without masks. If no HSPVA students have been exposed to your child please note that in the comment box. (Required.)

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14. EXPOSURE. While on the Kinder HSPVA campus was the student exposed to someone that tested or is presumed positive for COVID-19? (Required.)

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15. EXPOSURE. While away from Kinder HSPVA campus at home or out in the community was the student exposed to someone that tested or is presumed positive for COVID-19? (Required.)

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16. EXPOSURE. What is the date of the student's FIRST exposure to someone that tested or is presumed positive for COVID-19?

Date

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17. EXPOSURE. What is the date of the student's LAST exposure to someone that tested or is presumed positive for COVID-19?

Date

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18. PRESUMED or CONFIRMED POSITIVE. What symptoms of COVID-19 does the student have? (Required.)

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19. Please list any additional symptoms the student has experienced.

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20. PRESUMED or CONFIRMED POSITIVE. If the student is having one or more symptoms of COVID-19 what was the FIRST day the symptoms begin?

Date

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21. PRESUMED or CONFIRMED POSITIVE. Where was the student when they begin to feel sick?

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22. Did the student get a COVID-19 test? (Required.)

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23. What type of COVID-19 test did your student receive?

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24. What day was the sample collected from the student for a COVID-19 test?

Date

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25. What day were the results to the student's COVID-19 test received?

Date

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26. What was the location of the test site where the student received a COVID-19 test? Ex. CVS, Next Level Urgent Care, Minute Maid, doctors office, hospital, home test, etc. Write not applicable in the comment box if your student has not received a COVID-19 test. (Required.)

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27. What was the student's COVID-19 test result? (Required.)

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28. Did the student see a doctor for the COVID-19 symptom(s) experienced? (Required.)

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29. What date did the student see the doctor?

Date

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30. Household questions are included in the students electronic health record. How many are in your household? (Required.)

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31. How many in your household are currently or were recently (in the last 15 days) positive for COVID-19? (Required.)

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32. How many in your household attend school in HISD? (Required.)

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33. Please give the names of any children in your home that attend school in HISD (other than your child that attends HSPVA). Also, give the name of the school the child attends. If you have no other students attending HISD schools please note that in the comment box. 

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34. Vaccine questions are asked on HISD's COVID-19 report. Is your child vaccinated?

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35. Which vaccine did your student receive?

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36. What date did your child receive their first dose of the COVID-19 vaccine? (if known)

Date

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37. What date did your child receive their second dose of the vaccine? (if known)

Date

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38. Has your child received a booster dose of the COVID-19 vaccine?

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39. What date did your child receive their booster dose of COVID-19?

Date

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