Student COVID-19 Report Form

COVID-19 Student Report Form
If you are experiencing COVID-19 symptoms, please call your health provider or 911 if you have trouble breathing, chest pain, or other emergent conditions. If you have been recently exposed and you are not vaccinated, or if you have symptoms of COVID-19, please do not come to campus until you have been advised on your next steps.
Please complete this self-reporting form if you suspect you may have been exposed to someone with coronavirus (COVID-19) or experiencing symptoms of the virus or if you tested positive for COVID-19. This will help the College provide you with guidance about what you should do next.
Name of Person Reporting *

First Name Last Name
Student ID # *
Email Address *
example@my.cuesta.edu
Phone Number *
Please enter a valid phone number.
Are you fully vaccinated? (Fully Vaccinated Definition: Two weeks ormore have passed since the second dose in a 2-dose series (Pfizer or Moderna),or two weeks or more have passed since a single-dose vaccine (Johnson & Johnson). *
If symptomatic, date symptoms began, if known:

Month Day Year
Date
Date you may have been exposed to someone with coronavirus (COVID-19), if known:

Month Day Year
Date
Date of COVID-19 test, if known (this is the day you took the test, not when you received your results):

Month Day Year
Date
Were you on campus in the 48hours before your symptoms started or before the day you tested, if you are positive for COVID-19? If yes, what is the location you were at, if known?
Please share any details/concerns(e.g., course CRN, time, location about in-person classes or in-personservices, other campus activities, and public campus spaces (e.g., library,cafeteria) you may have visited. *
In submitting this form, you are authorizing Cuesta College to share limited health information with faculty and staff.
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COVID-19 Student Report Form