COVID-19 Report Form
Office Of Instruction
This form is only for providing information about students who have reported a positive COVID test. Providing this information is crucial to our contact tracing efforts, helps to keep our campuses safe, and is not considered to be a HIPAA violation.
If you have a student who has reported COVID symptoms, please encourage them to seek testing, isolate until they receive the test result, and work with them to make up missed assignments. Submit this form only if they report a positive test to you.
If you have a student who has reported that they may have been exposed, please direct them to the exposure reporting through the Student Health Center.
For all other issues, please email instruction@cuesta.edu.
Name of Person Reporting
*
First Name
Last Name
Reporter's Email Address
example@my.cuesta.edu
Information About COVID-19 Positive Individual
Answer the following questions as thoroughly as possible. Fields with the red asterisk are required.
Student Name
*
First Name
Last Name
Banner ID
Is this a student athlete?
*
Yes
No
Unknown
If symptomatic, date symptoms began, if known.
-
Month
-
Day
Year
Date
Date of COVID test, if known.
-
Month
-
Day
Year
Date
The last day the student was on campus, if known.
-
Month
-
Day
Year
Date
Please share any details (e.g. course, CRN, time, location) about in-person classes, other campus activities, and public campus spaces (e.g. library, cafeteria) the person may have visited. Also, confirm compliance with masking requirements.
*
Submit
Should be Empty: