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Now M-D-Y H:M
This survey may not be compatible with Internet Explorer or Edge and should be completed in Chrome.
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days. Does this scenario meet the definition of a potential outbreak?
* must provide value
Yes
No
Is this the first time you are filling out a report for this outbreak, or are you adding additional cases to an existing outbreak?
* must provide value
First time
Adding additional cases
First time
Adding additional cases
Since this does not meet the criteria of a suspect outbreak, you do not need to report this to the Fairfax County Health Department. For any other COVID related questions, please call 703-267-3511. Please exit the survey.
When answering the next question about outbreak setting, please note that all potential outbreaks related to public/private schools should select one of the K-12 options below. For example: an athletic team affiliated with a public high school should select K-12 FCPS. Recreational sports teams and clubs refer to those which take place in a community setting.
Outbreak Setting
* must provide value
K-12 FCPS K-12 FCCPS K-12 Private School Childcare (Daycare/Preschool) Recreational Sports Team (non-FCPS) Recreational Club/Group (non-FCPS)
Reporter Contact Information
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Reporter First Name
* must provide value
Reporter Last Name
* must provide value
Reporter Phone Number
* must provide value
Reporter Email
* must provide value
Please provide your principal's email address.
* must provide value
School Health PHN First Name
School Health PHN Last Name
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Name of School/Organization
* must provide value
Name of School
* must provide value
Aldrin ES Annandale HS Annandale Terrace ES Armstrong ES Baileys Lower ES Baileys Upper ES Beech Tree ES Belleview ES Belvedere ES Bonnie Brae ES Braddock ES Bren Mar ES Brookfield ES Bryant Alt Site Bucknell ES Bull Run ES Burke School Alt Site Bush Hill ES Camelot ES Cameron ES Canterbury Woods ES Cardinal Forest ES Carson MS Cedar Lane School Alt Site Centre Ridge ES Centreville ES Centreville HS Chantilly HS Cherry Run ES Chesterbrook ES Churchill Road ES Clearview ES Clermont ES Coates ES Colin Powell ES Columbia ES Colvin Run ES Cooper MS Crestwood ES Crossfield ES Cub Run ES Cunningham Park ES Daniels Run ES Deer Park ES Dogwood ES Dranesville ES Eagle View ES Edison HS Fairfax HS Fairfax Villa ES Fairhill ES Fairview ES Falls Church HS Flint Hill ES Floris ES Forest Edge ES Forestdale ES Forestville ES Fort Belvoir PS ES Fort Belvoir US ES Fort Hunt ES Fox Mill ES Franconia ES Franklin MS Franklin Sherman ES Freedom Hill ES Frost MS Garfield ES Glasgow MS Glen Forest ES Graham Road ES Great Falls ES Greenbriar East ES Greenbriar West ES Groveton ES Gunston ES Halley ES Haycock ES Hayfield ES Hayfield HS Hayfield MS Herndon ES Herndon HS Herndon MS Hollin Meadows ES Holmes MS Hughes MS Hunt Valley ES Hunters Woods ES Hutchison ES Hybla Valley ES Irving MS Island Creek ES Jackson MS Jessie Thackery Alt Site Justice HS Katherine Johnson MS Keene Mill ES Kent Gardens ES Key Center Key MS Kilmer MS Kilmer Center Kings Glen ES Kings Park ES Lake Anne ES Lake Braddock HS Lake Braddock MS Lane ES Langley HS Laurel Hill ES Laurel Ridge ES Lees Corner ES Lemon Road ES Lewis HS Liberty MS Little Run ES London Towne ES Longfellow MS Lorton Station ES Louise Archer ES Lynbrook ES Madison HS Mantua ES Marshall HS Marshall Road ES Mary Ellen Henderson MS Mason Crest ES McLean HS McNair Primary ES McNair Upper ES Meridian HS Mosaic ES Mountain View Alt Site Mt. Daniel ES Mt Eagle ES Mt Vernon HS Mt Vernon Woods ES Navy ES Newington Forest ES North Springfield ES Oak Hill ES Oak Street ES Oak View ES Oakton ES Oakton HS Olde Creek ES Orange Hunt ES Parklawn ES Pimmitt Hill Alt Site Pine Springs ES Poe MS Poplar Tree ES Providence ES Quander Road Alt Site Ravensworth ES Riverside ES Robinson HS Robinson MS Rocky Run MS Rolling Valley ES Rose Hill ES Sandburg MS Sangster ES Saratoga ES Shrevewood ES Silverbrook ES Sleepy Hollow ES South County HS South County MS South Lakes HS Spring Hill ES Springfield Estates ES Stenwood ES Stone MS Stratford Landing ES Sunrise Valley ES Terra Centre ES Terraset ES Thomas Jefferson HS Thoreau MS Timberlane ES Twain MS Union Mill ES Vienna ES Virginia Run ES Wakefield Forest ES Waples ES Washington Mill ES Waynewood ES West Potomac HS West Springfield ES West Springfield HS Westbriar ES Westfield HS Westgate ES Westlawn ES Weyanoke ES White Oaks ES Whitman MS Willow Springs ES Wolftrap ES Woodburn ES Woodlawn ES Woodley Hills ES Woodson HS Other
School/Organization Address - Street:
* must provide value
School/Organization Address - City:
* must provide value
School/Organization Address - ZIP:
* must provide value
Name of affected class/group (e.g., "Mrs. Smith's 3rd grade class" or "Boy's varsity basketball team" or "Ladybug Pre-K classroom")
* must provide value
How many student/attendee cases are involved in this outbreak?
* must provide value
How many employee/staff cases are involved in this outbreak?
* must provide value
View equation
You entered fewer than the minimum number of cases needed to proceed with an investigation. We need at least 3 cases to proceed with an outbreak investigation. If there are not 3 cases to report at this time, you do not need to complete this report.
How many total students/attendees are part of this class/team/club?
* must provide value
How many total employees/staff are part of this in the class/team/club?
* must provide value
Should this be determined to be an outbreak, the health department will recommend that at-home COVID-19 tests be sent home with all children/staff in the affected group/s. Does your facility have COVID-19 tests available for this purpose?
Yes
No
If this is determined to be an outbreak, information will be provided via email with instructions on how to access free COVID-19 tests in response to the outbreak.
Case Information In the fields below, please enter the case information for each individual associated with the outbreak. If the case is a student, please provide contact information for the parent/guardian. First Case:
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School/Organization:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your school/organization prior to becoming infected (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
* must provide value
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Is the case a student/attendee or employee?
* must provide value
Student/Attendee Employee
Employee/Staff Work Position
Case First Name
* must provide value
Case Last Name
* must provide value
Phone Number
* must provide value
Email
* must provide value
M-D-Y
When did symptoms start (if known)? Please leave blank if asymptomatic.
Today M-D-Y
Date Positive Result Reported to School:
* must provide value
Today M-D-Y
Last day at School/Onsite:
* must provide value
Today M-D-Y
Was this person exposed to someone with COVID outside of your facility (e.g., became sick from exposure to a COVID-positive household member)?
* must provide value
Yes No Unknown
Was this person reported as part of another cluster in the past 14 days?
* must provide value
Yes
No
Date case information provided to health department?
* must provide value
Today M-D-Y
A potential outbreak is defined as having three or more cases in a class/team/club in the last 14 days.
Please select any symptoms that cases experienced in this potential outbreak. Leave blank if you do not know.
Please provide any notes about the potential outbreak that may be helpful during the investigation process.
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