COVID Notification Reporting Form
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
(Please confirm the spelling of your email is correct as it is our primary point of contact)
*
Confirmation Email
example@westgatech.edu
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
Are you a faculty, staff or student member?
*
faculty
staff
student
Student ID Number
*
Please answer the following general screening questions:
Have you been in direct contact with someone who has tested positive for COVID-19 in the past 48 hours?
Yes
No
If yes, please enter the date of DIRECT exposure:
-
Month
-
Day
Year
Date
Was any Personal Protective Equipment worn when in contact?
Yes
No
How long were you in direct contact with the infected individual?
What was the estimated distance between you and the infected individual?
Have you experienced any COVID related symptoms in the past 24 hours (i.e. 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, diarrhea)?
*
Yes
No
Have you experienced new loss of taste and/or smell with no other explanation in the past 48 hours?
*
Yes
No
Have you experienced both fever (≥100.4° F) and new unexplained cough associated with shortness of breath in the past 48 hours?
*
Yes
No
Have you tested positive (from a PCR Antigen test) for COVID in the past 10 days?
*
Yes
No
If yes, please provide the date of the test:
-
Month
-
Day
Year
Date
Are you currently awaiting results from a PCR Antigen COVID test?
*
Yes
No
If yes, please provide the date of the test:
-
Month
-
Day
Year
Date
Are you under the care of a healthcare provider for COVID?
*
Yes
No
Have you been diagnosed with COVID by a licensed healthcare provider in the past 10 days?
*
Yes
No
If yes, please provide the date of the diagnosis:
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Month
-
Day
Year
Date
OPTIONAL: Have you completed all required doses of one of the COVID vaccinations available?
Yes
No
I'd prefer not to say
If yes, what was the date of your last vaccine dose (If no, or you prefer not to say, type "NA")?
*
Campus affiliation:
*
Murphy
Carroll
Coweta
Douglasville
LaGrange
Greenville
Franklin
Adamson
Local high school
CEC
CCA
CCI
thINC
Online
Last date on a WGTC campus:
*
-
Month
-
Day
Year
Date
Campus visited on the above date:
*
Murphy
Carroll
Coweta
Douglasville
LaGrange
Greenville
Franklin
Adamson
Local high school
CEC
CCA
CCI
thINC
Online
Were you in close contact with any faculty, staff, or students at the above listed campus, on the above date?
Yes
No
Please provide any additional information of importance regarding this notification report:
*
Submit
Should be Empty: