COVID-19 Self-Report

COVID-19 Self-Report

Please fill this form out if you have had direct contact with an individual who has tested positive for COVID-19 and you have been exposed or if you have tested positive for COVID-19.
I am a: *

Student Employee
My student type: *

On-Campus Student Online Student (in Prescott, AZ) Online Student (outside Prescott, AZ)
Name *

First Name Last Name
Cell Phone *

Area Code Phone Number
Email *
user.name@student.prescott.edu
Have you been directly exposed to an individual who has tested positive for COVID? *

Yes No
Have you arranged to get tested for COVID? *

Yes No
Have you tested positive for COVID? *

Yes No
Do you have the ability to self-isolate? *

Yes No
Do you have access to medical care? *

Yes No
Do you need to arrange academic adjustments or accommodations? *

Yes No
You will be contacted by Student Affairs to initiate contact tracing. If you have tested positive or have been in direct contact with an individual who has tested positive, please remain at home and isolate. If you need to arrange for testing, please contact your health provider. If you need to academic adjustments or accommodations, please contact christina.fabrey@prescott.edu.
You will be contacted by Human Resources to initiate contact tracing. If you have tested positive or have been in direct contact with an individual who has tested positive, please remain at home and isolate. If you need to arrange for testing, please contact your health provider. If you need to academic adjustments or accommodations, please contact Human Resources at susan.krause@prescott.edu.
Should be Empty: