Illness Reporting Form - EOSC at Southeastern

Illness Reporting Form

You are being asked to complete this form to help contain the spread of COVID and COVID-like illness within the McCurtain County Campus community.
By completing this form, you acknowledge that
1. What is contained in it is accurate to the best of your ability
2. I understand I will be contacted by an employee of EOSC to gain more information to assist us with appropriate care measures for you and illness tracking within our campus community
3. We may use the information to notify your work supervisor and/or professors on the SE-MCC campus, in general terms, regarding the need to take a medical absence until such time it is deemed appropriate to return to campus safely.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Are you considered:*

EOSC StudentEOSC FacultyEOSC StaffI am a SE student, faculty, or staff member (https://form.jotform.com/201426138264046)
I am completing this form because:*

I completed my self-assessment required before reporting to campus and noticed I had some of the symptomsI was diagnosed with COVID and have been instructed to isolate at homeI was exposed to or engaged in behavior that has prompted officials to advise me to quarantine at home at this timeI am unsure if my situation warrants completion of this form and would like to be contacted to discuss my special considerations and what steps I should take
Should be Empty: