Home Health Check Reporting Form

This self-reporting form is to notify Brownell Talbot of persons believed to be exposed to COVID-19, including students or members of a BT family household. This form may also be used to report recent or upcoming travel. Information reported in this form will be used by a designated BT administrator to determine appropriate follow-up.

Brownell Talbot will make every effort to protect personally identifiable information shared and will not disclose your identity or the identity of anyone with a COVID-19 diagnosis unless disclosure to Safety Team personnel is necessary or is otherwise required by law. The school may be required to report details, such as temperatures, symptoms, or diagnoses, to public health authorities and other governmental agencies.

Complete the Form