School/Child Care COVID-19 Self-Report Form - Individuals 2 Years and Older

COVID positive person information

Please follow these guidelines when completing this form:

This form is for children, students, staff, and teachers in PreK-12 and child care settings.

Complete a separate form for each individual you are reporting.
Report only individuals who attend/work at a school or child care facility in Livingston County, Michigan.

1. Legal first name of COVID positive person *This question is required.

2. Legal last name of COVID positive person *This question is required.

3. Date of birth of COVID positive person *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Parent/Guardian full name (if reporting for student/child) *This question is required.

5. What is the address of the COIVD positive person? *This question is required.

Street Address
City
Zip Code

6. Phone number (numbers only - area code and phone number) *This question is required. This question requires a valid number format.

7. Email *This question is required.

8. Enter date of symptom onset or date of test (if no symptoms) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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9. Type of test (If multiple tests were conducted, indicate the earliest positive test type) *This question is required.

10. Attach positive test results. Allowable files include: png, gif, jpg, jpeg, doc, xls, docx, xlsx, pdf, and txt. *This question is required.

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