G-PISD STUDENTS - Self-Report Form for Recent Travel and/or Symptoms

All information reported is voluntarily submitted to G-PISD for review by the School Nurse at your child's campus. We thank you for your support in working with us for the benefit of all students and staff.

Question Title

* 1. Please enter your contact information.Thank you!

Your First & Last Name (Person submitting form) *

Student's FULL NAME (Legal) *

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. What is your relationship to the student? (Mother, Father, Legal Guardian, etc.)

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* 3. What campus does your student currently attend?

G-P High School

G-P Middle School

East Cliff Elementary School

S.F. Austin Elementary School

T.M. Clark Elementary School

W.C. Andrews Elementary School

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* 4. Acting as the student's parent/guardian, has this student traveled to an area with known COVID-19 cases in recent days (inside or outside the country)?

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* 5. Where did he/she travel (city, country, location)?

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* 6. How long was the student there, and on what dates?

Date / Time of Arrival

Date

Time

AM/PM

Date / Time of Departure (to Return Home)

Date

Time

AM/PM

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* 7. Does the student currently have any symptoms or feel ill in any way? Please explain as you may feel appropriate for school purposes. (Again, information provided is voluntary.)

Thank you for sharing this voluntary information with us. Any responses you choose to provide will be kept confidential and only for use in supporting your family and planning for future school day(s) as we prepare to serve all students. If necessary depending on the information provided, we may contact you and provide information for you to contact the local Health Dept. directly. Thank you again!