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:*

StudentEmployee
My student type:*

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

First NameLast Name
Cell Phone*

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

YesNo
First date of exposure

MonthDayYear
Date
Last date of exposure

MonthDayYear
Date
Have you arranged to get tested for COVID?*

YesNo
Have you tested positive for COVID?*

YesNo
Do you have the ability to self-isolate?*

YesNo
Do you have access to medical care?*

YesNo
Do you need to arrange academic adjustments or accommodations?*

YesNo
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.
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