Weimar ISD COVID Test Request Form

Leslie Kloesel, RN - WISD District Nurse
lkloesel@weimarisd.org
979-725-6331

This form is for Weimar Independent School District Employees and Students to request on-site COVID-19 testing. If you are not an employee or student of WISD and are seeking testing for COVID-19, you should not use this form.
Please contact your local doctor for testing sites available.

This form must be filled out in it's entirety in order to make the testing process go smoothly.
For questions, please contact Leslie Kloesel, RN.

Campus:
Drivers License Numberrequired
First Namerequired
Last Name:required
Date of Birth:required
Race/Ethnicity:required Select all that applies
Other:
Home Addressrequired Address, City, County, State, Zip Code must all be provided.
Phone Numberrequired
Is this the first test (of any kind) you have had for COVID-19 testing?required
IF NO, what type of test have you had before?
IF NO, what is the date of the last test?
Are you having any COVID-19 symptoms?required
If yes, you MUST check all symptoms that apply.required
Date Symptoms Started or Direct Contactrequired
Date to be tested:required Day, Month/Date/Year
Please select which testing time will work for you.required