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COVID-19 Notice of Self-Report

Please complete the form below. Required fields marked with an asterisk (*).

First Name*

Answer Required

Last Name*

Answer Required

Employee ID #*

Answer Required

Position*

Answer Required

Please check the appropriate box*

Answer Required

I have been fully vaccinated and boosted.

I have NOT been fully vaccinated and boosted.

Check all that apply. *

Answer Required

Tested positive with the novel coronavirus, also known as COVID-19.

Directly exposed to someone that has tested positive for COVID-19.

Quarantined per health department/CDC guidelines.

Last Day at Work*

Answer Required

Date You Tested Positive

Do not enter a date if you are not positive.

Answer Required

Date of Your Symptom Onset (if any)

Answer Required

Name of Lab Where You Tested

Answer Required

Lab Address

Answer Required

Lab Phone Number

Answer Required

Bartlett City Schools will keep all medical information confidential and will only disclose it on a need-to-know basis. Please note that we will attempt to notify those that had close contact with you to advise them to monitor themselves for symptoms as one of our employees has tested positive for the virus. This notification may lead to others concluding that you have the virus due to your absence from work. Please know that your privacy is a priority, however we must also make provisions to provide for the safety of all employees and students within the district. Contact Geniese Bolden, School Health Coordinator, ([email protected]) with concerns.

Contact Benefits ([email protected]) to apply for a leave of absence.

For more information on COVID-19, including symptoms and treatment, visit the CDC website at www.cdc.gov (https://www.cdc.gov/).

Confirmation Email

Confirmation Email *

Email Required