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COVID-19 Exposure Health and Safety Intake Form

Faculty, staff, or students who are staying home due to symptoms, concerns, or diagnoses of COVID-19 and have been exposed to Covid-19 should complete this confidential health and safety intake form.

If a healthcare provider or medical professional has confirmed the Coronavirus/COVID-19 diagnosis, please do NOT to come to campus.

If the diagnosis is suspected, but not yet confirmed, please call your healthcare provider and call the college again when the results are in. DO NOT come to campus until you have received further guidance from a contact tracer.      

Are you experiencing symptoms? When did they start?
For Pfizer and Moderna, please fill out both vaccination dates if you have received them. For Johnson & Johnson, please fill out the first vaccination date only.

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