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 Name
Last Name
Email
*
example@example.com
Cell Phone
*
-
Area Code
Phone Number
Enter your Date of Birth
*
Your affiliation with Nunez
*
Faculty/Staff
Student
Visitor
Choose a Response
*
Confirmed COVID-19 case
Potential COVID-19 case (symptoms or close contact)
Notification of Self or Medical Quarantine
On what date did you test positive or come in contact with a COVID positive person?
*
-
Month
-
Day
Year
Date
Do you have symptoms?
*
Yes
No
If yes, what symptoms are you experiencing? If no, type NA.
*
NA
What date did your first symptom(s) occur?
*
-
Month
-
Day
Year
Date
If you are a student, what mode of delivery are you currently enrolled in?
On Campus Classes Only
Virtual Classes Only
Both On Campus and Virtual Classes
When were you last on campus?
*
-
Month
-
Day
Year
Date
Last date believed to have been in contact with someone exposed to COVID-19
*
-
Month
-
Day
Year
Date
Are you fully vaccinated?
Yes
No
Received First Round for Vaccination
Have you received the booster shot?
Yes
No
*
*
Submit
Should be Empty: