COVID At-Home Test Attestation Form

Complete this form ONLY if you are symptomatic, took an At-Home COVID test, and tested positive. A PCR follow-up test IS REQUIRED within 5-days of testing positive on a home/antigen test. The PCR results must be submitted to the nurse.


Student Name(Required)
MM slash DD slash YYYY
At-Home COVID Test Result(Required)
Photo of Test Results(Required)
Accepted file types: jpg, jpeg, png, gif.

Parent Electronic Signature