WCJC COVID-19 Self-Reporting Form

WCJC COVID-19 Employee Self-Reporting Form (AY 2022)
Full Name *

First Name Last Name
WCJC Email *
Contact Number *

Area Code Phone Number
WCJC ID *
County of Residence *
Cabinet-Level Affiliation: *

President Vice President of Instruction Vice President of Administrative Services Vice President of Technology Vice President of Planning and IE
Which of the following pertains to your situation? *

Experiencing new or worsening symptoms associated with COVID-19 Received a confirmed positive test for COVID-19 Are residing with a family member who has been diagnosed with COVID-19
Are you currently experiencing symptoms consistent with COVID-19? *

Yes No
What date did you (or the other individual) get tested for COVID-19 or begin exhibiting signs/symptoms of COVID-19?

Month Day Year
Date
Are you fully vaccinated for COVID-19? Defined as 2 weeks after second dose in a 2-dose series (Pfizer or Moderna) or 2 weeks after a single-dose vaccine (Johnson & Johnson). *

Yes No
Have you been to a WCJC campus within the last two weeks? *

Yes No
What was the last day that you were on campus?

Month Day Year
Date
Which campus(es) have you been to in the past two weeks? *

Bay City Richmond Sugar Land Wharton Not Applicable (I have not been on campus)
If applicable, please list the buildings/areas that you visited while on campus. Please be very descriptive regarding where you went while on campus, at what times, and who you may have in contact with. *
By entering my name, I certify that all information contained in this report is true and correct.
Enter Full Name Here
Should be Empty:

WCJC COVID-19 Employee Self-Reporting Form (AY 2022)