ADMIN ONLY: MNTC Symptom & Exposure Report

MNTC Symptom & Exposure Report
Complete this form if:
1. 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
2. In the last 14 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 14 days, I was exposed to or cared for someone diagnosed with COVID-19. Public transit 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? *

Month Day Year
Date of Exposure

Month Day Year Hour Minutes 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 14 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.
Should be Empty: