SELF-REPORTING FORM
This self-reporting form is to notify the Administration at Nunez Community College of persons believed to be exposed to the Coronavirus (COVID-19), including yourself. Information reported in this form will be used by a designated Nunez Administrator (Employee=HR Director, Students=Vice Chancellor for Student Affairs) to determine appropriate follow-up. Nunez Community College will take every effort to protect personally identifiable information shared in this document and will not disclose your identity or the identity of anyone with a Coronavirus diagnosis unless disclosure to safety and first aid personnel is required for emergency treatment or is otherwise required by law. The College may be required to report details, such as temperatures, symptoms, or diagnoses, to public health authorities and other governmental agencies.
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone
*
-
Area Code
Phone Number
Enter your Date of Birth
*
Your affiliation with Nunez
*
Faculty/Staff
Student
Visitor
Choose a Response
*
Confirmed COVID-19 case
Potential COVID-19 case (symptoms or close contact)
Notification of Self or Medical Quarantine
Do you have symptoms?
*
Yes
No
What date did symptoms begin?
*
-
Month
-
Day
Year
Date
Last date believed to have been in contact with someone exposed to COVID-19
*
-
Month
-
Day
Year
Date
*
*
Submit
Should be Empty: