MNTC Symptom & Exposure Report
Complete this form if:
In the last 24 hours have you experienced a cough, sore throat, respiratory illness, shortness of breath/difficulty breathing, or any other cold or flu-like symptoms
In the last 14 days, you were exposed to or cared for someone diagnosed with COVID-19.
I am a/an MNTC:
What site is your primary place of work or study?
Franklin Road Campus - A or B Area (e.g., Near Admin / Assessment / Student Services)
Franklin Road Campus - C or D Area (e.g., Near Welding/Cosmetology)
Franklin Road Campus - Technical Trades Building (i.e., HVAC or Electric)
Franklin Road Campus - Carpentry Building
Franklin Road Campus - Bus Barn
Franklin Road Campus - BIT Building (e.g., Near Graphic Design or Networking)
Franklin Road Campus - Health Building (i.e. Any health program)
Franklin Road Campus - HIRE Building
South Penn Campus - Conferencing Side
South Penn Campus - Educational Side
South Penn Campus - North Building (Formerly BDC)
Which situation are you reporting?
In the last 24 hours I experienced a cough, sore throat, respiratory illness, shortness of breath/difficulty breathing, or any other cold or flu-like symptoms.
In the last 14 days, I was exposed to or cared for someone diagnosed with COVID-19.
Close contact in a social setting of 10 or more people
Give us a description of travel:
Give description of social setting"
What symptoms have you experienced in the last 24 hours?
When did you begin experiencing symptoms?
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Date of Exposure
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Where did the exposure take place?
Has the person to whom you were exposed tested positive for COVID-19?
Have you had a COVID-19 test performed?
Result of test
Have you been on MNTC's campus any time in the last 14 days?
Please provide any additional information that might help us respond to this situation.
I certify to the best of my knowledge; the information provided in this form is accurate.
Yes, the information is accurate.
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