COVID-19 Student Self Reporting Form

Students: Please complete this form ONLY if you have tested positive for COVID-19. Responses will be submitted to the Vice President of Student Services, and your name and contact information will be shared with the local health department for contact tracing purposes. A college official will contact you to identify others with whom you have had close contact. The identified parties will be notified only that they have been in contact with someone who tested positive for COVID-19; names and identities will not be shared.
Name * Required
First Middle Last
Student ID #

Please include leading zeros. The full ID # should be 7 digits long.
This can be found on your student ID card.
Address * Required
Street Address Address Line 2 City State ZIP Code
Date of Birth - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Phone * Required
Email * Required
Date Symptoms Started - must be mm/dd/yyyy format
MM slash DD slash YYYY
Date of Positive Test - must be mm/dd/yyyy format
MM slash DD slash YYYY