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—are required to self-quarantine. Name * Required First Last SIS # * RequiredEmail * Required Phone * RequiredQuestions:Have you been tested for COVID-19? * RequiredYesNoWhen were you tested? - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Do you plan to get tested?YesNoIf yes, when? - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY What was your result?NegativePositiveI plan to self-quarantine in accordance with CDC recommendations. * Required Yes Are you taking a face-to-face or hybrid course? * RequiredYesNoPlease complete the following for each face-to-face class:InstructorClass NameSection Number
