Student COVID Reporting Form

Background Information

Please report any of the following situations:
- Currently experiencing symptoms of COVID-19,
- Need to quarantine due to close contact with a positive case of COVID-19,
- Diagnosis by a Licensed Healthcare Professional for COVID-19,
- Positive test result for COVID-19, and/or
- Caring for someone who was diagnosed with or tested positive for COVID-19.

Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Learn more

Choose if you are reporting for yourself or on behalf of a student

Urgency of this report(Required):

This field is required.

Date of exposure/test/symptoms(Required):

This field is required.

Last Date on Campus:

Campus you attend(Required):

This field is required.

Specific Building/Rooms?:

Involved Parties

Please list yourself and any classmates or instructors you have come in contact with. If you were exposed to COVID-19 by a student or employee please also list this person. If you are completing this on behalf of a student, include the student information.

Name

Select Gender

ID Number

Phone number

Email address

Questions

Please answer all questions before submitting report.

Please explain your situation in detail. Do you have symptoms? Have you tested Positive? Were you exposed? What date were you exposed, symptoms began or/ and tested positive? If completing on behalf of a student, include student and all information you have.(Required) This field is required.

Provide the details of how the contact occurred? Was it indoors or outdoors? Describe any protective equipment you and/or the other person(s) were wearing (masks, gloves, goggles etc or any other PPE) during the times you were interacting. Give details of any continued contact with the person(s) (Are you living with the person(s) or still have repeated contact with them?) Was the person you came in contact with experiencing symptoms then or now? Describe the interaction you had with them and length (in total minutes - does not have to be all at once). How far away were you from them (in feet) - especially when you were closer than 6 feet to the person(s). If completing on behalf of a student, include all information you have.(Required) This field is required.

Please give detailed information on any interactions with any other COA students, faculty or staff, either on or off campus, that you have had since the original exposure occurred. Give as much detail as you can about your interactions. Describe the interaction you had with them - for how long (in total minutes - does not have to be all at once). How far away were you from them (in feet) - especially when you were closer than 6 feet to the person(s). If completing on behalf of a student, include student interaction in your class and all other information you have.(Required) This field is required.

If you are a student, which program of study are you in? Have you advised your instructor?(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission