COVID-19 Contact Authorization

1

Should your student experience any of the following:

Close contact with someone who tested positive for COVID-19
Experiencing COVID-19 symptoms
Recent positive COVID-19 test (within 14 days)
Ordered by local Public Health Department or medical department to quarantine/isolate

We would need your authorization for a Cal Poly Pomona Incident Investigation team to contact your student and discuss information regarding contact tracing for COVID-19

*PLEASE CONTINUE ON THE NEXT SLIDE FOR THE AUTHORIZATION

2

I First Name Last Name authorize the Cal Poly Pomona Incident Investigation team to contact my student First Name Last Name to discuss any COVID-19 incidents and provide guidance and instructions for next steps.

3

Parent Signature* This field is required.

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