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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
OR
In the last 10 days, you were exposed to or cared for someone diagnosed with COVID-19.
Name
*
First Name
Last Name
I am a/an MNTC:
*
Employee
Board Member
Student
Visitor
Vendor
Contractor/Construction Worker
Organization?
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)
Warehouse
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
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 10 days, I was exposed to or cared for someone diagnosed with COVID-19 and I am not fully vaccinated and/or I have not recovered from COVID-19 within the last 90 days.
Commercial transit such as airplane, boat, or commercial bus (e.g. Greyhound Lines)
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?
*
-
Month
-
Day
Year
Date Picker Icon
Date of Exposure
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Where did the exposure take place?
*
Has the person to whom you were exposed tested positive for COVID-19?
*
Yes
No
Unsure
Have you had a COVID-19 test performed?
*
Yes
No
Result of test
Positive
Negative
Have you been on MNTC's campus any time in the last 10 days?
*
Yes
No
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.
Submit
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