Self Reporting Form

SELF-REPORTING FORM

This self-reporting form is to notify the Administration at Nunez Community College of persons believed to be exposed to the Coronavirus (COVID-19), including yourself. Information reported in this form will be used by a designated Nunez Administrator (Employee=HR Director, Students=Vice Chancellor for Education, Training and Student Success) to determine appropriate follow-up. Nunez Community College will make every effort to protect personally identifiable information shared in this document and will not disclose your identity or the identity of anyone with a Coronavirus diagnosis unless disclosure to safety and first aid personnel is required for emergency treatment or is otherwise required by law. The College may be required to report details, such as temperatures, symptoms, or diagnoses, to public health authorities and other governmental agencies.
Name*

First NameLast Name
Email*
example@example.com
Cell Phone*

Area CodePhone Number
Enter your Date of Birth*
Your affiliation with Nunez*
Choose a Response*
On what date did you test positive or come in contact with a COVID positive person?*

MonthDayYear
Date
Do you have symptoms?*
If yes, what symptoms are you experiencing? If no, type NA.*
NA
What date did your first symptom(s) occur?*

MonthDayYear
Date
If you are a student, what mode of delivery are you currently enrolled in?
When were you last on campus?*

MonthDayYear
Date
Last date believed to have been in contact with someone exposed to COVID-19*

MonthDayYear
Date
Are you fully vaccinated?
Have you received the booster shot?
*
*
Should be Empty:

SELF-REPORTING FORM