MNTC Exposure Report

MNTC COVID-19 Exposure Report
Please complete this form to report an exposure to COVID-19. If you have been exposed do NOT come on campus. You may also use this form to report a known exposure to COVID-19 on campus.
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
Date of Exposure

Month Day Year
Date Hour Minutes AM/PM Option
Where did the exposure take place? *
Has there been a confirmed COVID-19 test performed?

Yes No Unsure
Is self-isolation being practiced?

Yes No Unsure
Signature *

Clear
Should be Empty:

MNTC COVID-19 Exposure Report