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*

First Last

Phone*

SIS #*

TCC Student Email*

Questions:

The following COVID-19 situation is being reported*

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.*

What day where you tested? Note "n/a" if unsure or prefer not to answer.*

What date were you last exposed to this person? Note "n/a" if unsure or prefer not to answer.*

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Do you know the date you were exposed to COVID-19?*

Yes
No
I prefer not to answer

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What date were you exposed to COVID-19*

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Have you been tested for COVID-19?*

Yes
No

Hidden

When were you tested?

Hidden

Do you plan to get tested?

Yes
No

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If yes, when?

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What was your result?

Negative
Positive

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Are you fully vaccinated?*

Yes
No
Prefer not to answer

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Have you had COVID-19 within the past 3 months?*

Yes
No
I don’t know
Prefer not to answer

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I plan to self-quarantine in accordance with CDC recommendations.*

Yes

Are you taking a face-to-face or hybrid course?*

Yes
No

Please complete the following for each face-to-face class:

Instructor	Class Name	Section Number

Additional Comments: