COVID-19 Symptoms, Testing, or Positive Test Information

COVID-19 Symptoms, Testing, or Positive Test Information
Introduction and Instructions

Please answer the questions below to the best of your ability. If you do not know the answer or if it does not apply, leave the answer blank, or enter N/A as needed.

Faculty and staff submitting a report on behalf of a student can email their report to the Health and Safety Coordinator, Ryan Hughes (928)226-4356 or ryan.hughes@coconino.edu

CCC will follow-up with anyone who completes this form for additional information. If needed, the Incident Management Team will coordinate the appropriate cleaning and disinfecting of any affected spaces on campus and address any other concerns that may arise.

When possible, all personal information will be kept confidential. Any notifications made will not include personal identifying information.
Are you filling this form out:*

For myselfOn behalf of an employee (faculty, staff, or student employee)On behalf of a student
Have you or the person you are concerned about:*

Reported symptoms of COVID-19Received a positive test result for COVID-19
Contact Information for the Individual Completing this Form
Name *
Department/Division
Phone Number*

Area CodePhone Number
Email*
example@example.com
The remainder of this form focuses on the person who has been experiencing symptoms, or has tested positive for COVID-19. Please fill out the remaining information for that individual.
Contact Information for Reported Symptoms, or Tested Positive Individual
Name*

First NameLast Name
Are you a:*

StudentEmployee (faculty or staff member including student and federal work study employees)Contract Employee (Bookstore, Custodial, Deli, etc.)
What campus do you take most of your classes on?*

Lone TreeFourth StreetPageOnlineI'm answering for someone else and don't have this information
Do you work for:*

Follett - CCC BookstorePinnacle Jantorial - Custodial ServicesNAUOther
Department/Division*
Home Address (where you are currently living)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Gender*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Comet ID (username for my CCC)
Student or Employee ID Number (@00.....)
COVID-19 Information for Reported Symptoms, or Tested Positive Individual
The remainder of this form focuses on the person who has been experiencing symptoms, has been exposed, or has tested positive for COVID-19. Please fill out the remaining information for that individual.
What does close contact to someone with COVID-19 mean?

Close contact is currently defined by the CDC as someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.
Have you been exposed to COVID-19?

YesNoI'm answering for someone else and don't have this information
Have you been in close contact with someone who has COVID-19?*

YesNoI'm answering for someone else and don't have this information
What does close contact to someone with COVID-19 mean?
The CDC defines close contact as someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period (for example, three individual 5-minute exposures for a total of 15 minutes) starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.
Date of Possible Exposure/Close Contact*

MonthDayYear
Are you living with someone who has tested positive for COVID-19?*

YesNoI'm answering for someone else and don't have this information
Have you had a COVID-19 test?*

YesNoI'm answering for someone else and don't have this information
COVID-19 Test Date*

MonthDayYear
Were your test results:*

Positive - I have COVID-19NegativeI'm still waiting for test resultsI'm answering for someone else and don't have this information
What date did you receive your test results?

MonthDayYear
Symptoms of COVID-19 include: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea.
Within the last 14 days, have you had COVID-19 symptoms?*

YesNoI'm answering for someone else and don't have this information
When did you start having COVID-19 symptoms?*

MonthDayYear
Please list any COVID-19 symptoms.*
Voluntary disclosure (not required): Are you...

Not vaccinatedPartially vaccinatedFully vaccinatedI'm answering for someone else and don't have this informationFully Vaccinated, Up to Date
Have you been to a CCC Campus or Center in the last 14 days?*

YesNoI'm answering for someone else and don't have this information
Which campus(es) or center did you visit?*

Flagstaff Lone Tree CampusFlagstaff Fourth Street Innovation CenterPage CenterI'm answering for someone else and don't have this information
What was the last date you were on campus?*

MonthDayYear
What is your office number or work location ?
What classes are you taking?
Please consider any of the locations when thinking about where you might have been the last time you were on campus.

Common spaces, classrooms, co-workers' offices, faculty offices, meeting rooms, computer lab, IT Help Desk, Welcome Center, Security, Student Affairs, etc.
Please list any locations that you may have been on each campus.
Common spaces, classrooms, offices, faculty offices, etc.
About what time were you on campus?
Close contact is currently defined by the CDC as someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.

Please consider faculty, staff, co-workers, IT Help Desk staff, Security Staff, other students, or friends on campus.
Is there anyone on campus that you were in close contact with?*
Would you be comfortable if we used your name when notifying the people you came in contact with?

YesNoI'm answering for someone else and don't have this information
In most cases, copies of COVID-19 test results will be needed to allow you to return to campus. If you have those items available, please attach them below.
Please attach COVID-19 test results to expedite your clearance.

Browse Files

Cancelof
Thank you
Thank you for taking the time to complete this form and assist CCC and Coconino County in reducing the spread of COVID-19. We are so sorry that you and your family are having to go through this.
Is there anything else you'd like us to know?
Is there any way someone from CCC can assist you at this time?
If you have not already done so, please make sure to contact your faculty members (students) or supervisor (employees).

Students/employees may only return to campus after following the CDC’s recommended quarantine period if there has been a resolution of fever for at least 24 hours without the use of fever-reducing medications and with improvement of other symptoms.

Security and Communication Notice

Coconino Community College is dedicated to the health and safety of all people. Therefore, the college will fully cooperate with the Coconino County Department of Health and Human Services (CCHHS) with aiding in tracing all known avenues of COVID-19 infections among staff, faculty, and students. Furthermore, CCC will be supplying CCHHS staff, through its encrypted web-based reporting portal, personal identification information that is exempted, during the pandemic, from the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA). This exempted information, includes: first and last name, address, date of birth, gender, phone number, date of illness onset, date last present in the facility, date of positive COVID-19 test, symptoms if reported, class schedule, and a list of people who were in close contact.
Should be Empty:

COVID-19 Symptoms, Testing, or Positive Test Information

Contact Information for the Individual Completing this Form

Contact Information for Reported Symptoms, or Tested Positive Individual

COVID-19 Information for Reported Symptoms, or Tested Positive Individual

Thank you