Student COVID-19 Report Form

COVID-19 Student Report Form
- Please complete this form if you are a student who has tested positive for COVID-19, or are reporting on behalf of a student who reported a COVID-19 case. This will help the College provide you with guidance about what you should do next.
- This form is for student cases only. If you are an employee reporting on behalf of yourself, please email hr@cuesta.edu.
- 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 symptoms of COVID-19 or you have tested positive, do not come to campus until you have been advised of your next steps.
Name of Person Reporting *

First Name Last Name
Student ID # *
Reporter's email address in case of follow up. *
example@my.cuesta.edu
Reporter's phone number in case of follow up *
Please enter a valid phone number.
If symptomatic, date symptoms began, if known:

Month Day Year
Date
Date of positive 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 48 hours 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-person services, 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.
Should be Empty:

COVID-19 Student Report Form