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Coronavirus COVID-19 Self Report
If you are experiencing symptoms related to the Coronavirus COVID-19, please submit this form.
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1
Your Name
*
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First Name
Last Name
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2
Your E-mail address
*
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example@student.prescott.edu
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3
Please describe the symptoms you are experiencing
*
This field is required.
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4
Where are you traveling from?
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5
Do you have the ability to self-quarantine?
*
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YES
NO
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6
Where will you be staying for that quarantine?
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7
What is the best way to contact you?
*
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Email
Phone
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8
Phone Number
Area Code
Phone Number
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9
Additional Comments
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