COVID-19 Employee Self Reporting Form
This form should be completed when you have symptoms, a test result to report, exposure to COVID-19 or other concerns. For the health and safety of our college community, self reporting of the COVID-19 illness is required. Be sure that the information you give is accurate and complete. It is important to seek medical attention if you have any of the COVID-19 signs. Please know this form is kept confidential.
Please provide a phone number
Department Name (if applicable)
Supervisor (if applicable)
Have you been in contact with a person who has tested positive for COVID-19 or is waiting for a result from a COVID-19 test?
If yes above, please tell us your relationship to the person, the date, duration and nature of the contact with the person/people.
Have you been contacted by a health department or official entity conducting contact tracing?
What instructions, if any, have you received from a health department or official entity regarding your situation? Please provide the written documentation to the Human Resources Director.
Have you tested positive for COVID-19 in the last 14 days?
Are you waiting for a result from a COVID-19 test?
If yes you are waiting for a result from a COVID-19 test, what date were you tested?
Please state whether you are experiencing the following symptoms? If you answer yes, please include the date the symptoms started below.
Shortness of Breath
Persistent Pain in the Chest
If yes, when did the symptoms begin:
Have you been in contact with a healthcare provider regarding your symptoms?
Are you able to work from home?
Students: Have you contacted Campus Life regarding your situation?
Type option 4
Employees: Have you contacted your Supervisor regarding your situation?
I acknowledge that the information I have given is accurate and complete.
Should be Empty: