WCJC COVID-19 Employee Self-Reporting Form
County of Residence
Vice President of Instruction
Vice President of Administrative Services
Vice President of Technology
Vice President of Planning and IE
Which of the following pertains to your situation?
Experiencing new or worsening symptoms associated with COVID-19
Believe that you were exposed to someone with COVID-19
Received a confirmed positive test, have been diagnosed with, or are being treated for COVID-19
Were tested for COVID-19 and are awaiting results of the test
Are providing care to or residing with a family member who has been diagnosed with, is experiencing symptoms, or has been tested for COVID-19
Have traveled internationally, on a cruise, or to any locations identified in the Governor's Executive Orders
Are you currently experiencing symptoms consistent with COVID-19?
What date did you (or the other individual) get tested for COVID-19, begin exhibiting signs/symptoms of COVID-19, or return from restricted travel?
Have you been on one of the WCJC campuses two weeks prior to or following the date entered above?
If yes, what was the last day that you were on campus? If no, please enter "N/A".
If yes, which campus(es) have you been to during that time?
Not Applicable (I have not been on campus)
If applicable, please list the buildings/areas that you visited while on campus. Please be very descriptive regarding where you went while on campus, at what times, and who you may have in contact with.
By entering my name, I certify that all information contained in this report is true and correct.
Enter Full Name Here
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