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COVID-19 Disclosure Form

Student disclosing COVID-19 exposure:
Please complete this form if any of the following apply:
- You have tested positive for COVID-19.
- You are experiencing any symptoms of COVID-19 within the past 10 days.
- You have been in "close contact" with someone who has COVID-19 within the past 14 days.
The CDC states that persons are considered to have “close contact” if they:

Were within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated. People who have been in close contact with someone who has COVID-19—excluding people who have had COVID-19 within the past 3 months or people who are fully vaccinated and do not have symptoms—are required to self-quarantine.
Name * Required
First Last
Phone * Required
SIS # * Required
TCC Student Email * Required
Questions:
The following COVID-19 situation is being reported * Required
- I am experiencing symptoms of COVID-19.
- I tested positive for COVID-19.
- I have had close contact with someone who was confirmed to have COVID-19.
What date did you first experience symptoms? Note "n/a" if unsure or prefer not to answer. * Required
What day where you tested? Note "n/a" if unsure or prefer not to answer. * Required
What date were you last exposed to this person? Note "n/a" if unsure or prefer not to answer. * Required
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Do you know the date you were exposed to COVID-19? * Required
- Yes
- No
- I prefer not to answer
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What date were you exposed to COVID-19 - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
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Have you been tested for COVID-19? * Required
- Yes
- No
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When were you tested? - must be mm/dd/yyyy format
MM slash DD slash YYYY
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Do you plan to get tested?
- Yes
- No
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If yes, when? - must be mm/dd/yyyy format
MM slash DD slash YYYY
Hidden
What was your result?
- Negative
- Positive
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Are you fully vaccinated? * Required
- Yes
- No
- Prefer not to answer
Hidden
Have you had COVID-19 within the past 3 months? * Required
- Yes
- No
- I don't know
- Prefer not to answer
Hidden
I plan to self-quarantine in accordance with CDC recommendations. * Required
- Yes
Are you taking a face-to-face or hybrid course? * Required
- Yes
- No
Please complete the following for each face-to-face class:
Instructor Class Name Section Number
Additional Comments:

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Instructor	Class Name	Section Number

Student disclosing COVID-19 exposure:

Questions: