COVID Contact Investigation Form

COVID - Contact Information Form

If you have tested positive for COVID-19, please complete the following form. The college will contact you and initiate a contact tracing investigation if appropriate. Please fill out the form to report a Corona-virus concern, exposure or provide results. We are striving for a response time of 24-48 hours, and will respond as soon as possible. Based on the information provided we will determine the appropriate course of action that will be shared with you and your supervisor. Please do not come onto campus until you have received further instructions.
Name

First Name Last Name
Email
example@example.com
Phone Number - for follow up if needed

Area Code Phone Number
Identification Number
Are you faculty/staff or student
I am completing the contact form because I have:

Student - please list courses that you physically attend face to face on campus. Faculty - please list courses you are physically teaching face to face on campus.

Course Name

Department #

Course #

Section #

Room #

Course #1

Course #2

Course #3

Course #4

Course #5

Please List Campus Location for Above Courses

Campus Location

Course #1

Course #2

Course #3

Course #4

Course #5

If you are an MATC Staff Member physically working on campus, please list your position title.
If you are an MATC Staff Member physically working on campus, please list your office number and campus location.
Have you physically been on any MATC campus(es) during the prior or past two weeks?
Student - please provide the date you were last in class. Faculty/Staff please provide date you were last on campus.

Month Day Year
Date
Were you tested for COVID
If Yes to above - Date Test Was Administered

Month Day Year
Date
Results of COVID Test (if administered)
Have You Experienced Symptoms of COVID - Please Describe
If You Have Experienced Symptoms of COVID - Please Identify Date When Symptoms Began

Month Day Year
Date
COVID - Contact Tracing

In order to define a close contact, please respond to these three questions below about each person that worked closely with you while on campus:
Did you have direct physical contact with anyone? (hug, kiss, handshake)
Were you within 6 feet of the person for more than 15 minutes. Remember, 15 minutes is not consecutive, it means over the course of the day.
Could you have had contact with any of their respiratory secretions (ex…cough, sneeze, sharing a drinking glass or other personal items)?

If you answer yes to any of the above questions then they are considered a close contact. We ask you to provide every close contacts name.

First Name

Last Name

Close Contact

Is there any additional information you would like to share?
Should be Empty:

COVID - Contact Information Form

COVID - Contact Tracing