WCJC COVID-19 Employee Self-Reporting Form
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 Strategy, Enrollment Mgmt, and Technology
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) begin exhibiting signs/symptoms of COVID-19?
-
Month
-
Day
Year
Date
What date did you (or the other individual) get tested for 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 received a booster?
*
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
Submit
Should be Empty: