WCJC COVID-19 Self-Reporting Form

WCJC COVID-19 Self-Reporting Form

This reporting form is for students and employees to notify the College of incidents/persons believed to be affected by the Coronavirus (COVID-19), including your own.
Full name: *
College affiliation: *

Student Faculty Staff
Nature of the report (please indicate the reason for this report): *
Urgency of the report: *
Choose a campus location: *

Wharton Richmond Sugar Land Bay City
Which WCJC location do you work at or attend?
Where did the incident occur? (indicate specific location)
Please provide information regarding person(s) believed to be affected by COVID-19
Name of person(s) believed to be affected:
Is this individual a WCJC student?

Yes No
Student/employee ID number:
Student/employee's email address (if known):
example@wcjc.edu
Student/employee's phone number (if known):

Area Code Phone Number
Please provide additional information
Are you currently sick? *

Yes No
Dates believed to have been in contact with someone affected by COVID-19 (please provide calendar dates) *
I acknowledge by submitting this form, that I will not be allowed to return to a Wharton County Junior College location until at least 14 calendar days after notice of contact/exposure to COVID-19. *

I acknowledge
By submitting this form, I am self-quarantining myself. I am also notifying Wharton County Junior College that I am aware that I must receive written approval from WCJC prior to returning to any campus. *

I acknowledge
I attest the information provided is true and correct to the best of my ability and understand that any false statements/allegations may be subject to disciplinary actions including but not limited to expulsion or termination. *

I acknowledge
Should be Empty: