COVID-19 Exposure Report

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of this report(Required):

This field is required.

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Please select the option that best describes your situation

Time of incident:

Specific location:

Involved Parties

Involved party 1

Full Name

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

LakeHawk Email address (Only)

Questions

If you have tested positive, what date did you test? (Indicate N/A If not applicable)(Required) This field is required.

If you have tested positive, what date did you receive your test results? (Indicate N/A If not applicable)(Required) This field is required.

If you were exposed to someone who tested positive, what date were you exposed? (Indicate N/A If not applicable)(Required) This field is required.

Are you experiencing symptoms for COVID?(Required) This field is required.

If you are you experiencing symptoms for COVID, what are your symptoms? (Indicate N/A If not applicable)(Required) This field is required.

If you are you experiencing symptoms for COVID, when did your symptoms start? (Indicate N/A If not applicable)(Required) This field is required.

Have you been fully vaccinated?(Required)

Yes No

You must make at least one selection.

What was the month and year of your last vaccination dose? Example: March 2021 (Indicate N/A If not applicable)(Required) This field is required.

Have you received a booster? If yes, when did you receive your booster? Example: November 2021 (Indicate N/A If not applicable)(Required) This field is required.

What was the last day(s) you were physically present on any LSSC Campus? Example: Monday 8/30/21 (Indicate N/A If not applicable)(Required) This field is required.

If you were recently on campus, what campus were you on? (Indicate N/A If not applicable)(Required)

South Lake (Clermont) Sumter Leesburg N/A

You must make at least one selection.

If you were recently on campus, where did you go and for approximately how long were you there? (Indicate N/A If not applicable)(Required) This field is required.

Would any of your recently held, on campus classes, be impacted by your exposure? If Yes, please list the name of the course(s), the CRN(s), and when they met, so that we can determine if contact tracing is needed. (Indicate N/A If not applicable)(Required) This field is required.

If we need to reach you for clarification of the information you have provided, what is the best phone number for us to use?(Required) This field is required.

Is there anything else you would like us to know about your case? (Indicate N/A If not applicable)(Required) This field is required.

Are you a high school Dual Enrollment Student?(Required)

No Yes - Lake County Public Schools Student Yes- Sumter County Public Schools Student Yes- Private High School Student Yes- Home School Student

You must make at least one selection.

Have you been self isolating? If yes, when did you begin to self isolate? Example: Monday, December 27, 2021 (Indicate N/A If not applicable)(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Select copy recipients

scottc@lssc.edu

nathansr@lssc.edu

hickmonk@lssc.edu

Background Information

Involved Parties

Questions

Supporting Documentation

Select copy recipients

Submission