Employee COVID-19 Self Reporting Form

Employees, please complete the following form if you experience COVID-19 symptoms, test positive (or a health care provider tells you that you are presumed positive), or if someone in your immediate household has symptoms or has tested positive.

Disclaimer: Information submitted on this form will be shared ONLY with limited College officials, including our Health Educator and Public Safety team. This information will be used to determine whether additional cleaning and other response actions (including relevant notifications) need to be taken on campus. It is being stored confidentially and securely, and will not be included in an official medical, student, or employee record or file.

Are you a student or employee? * Required
- Employee
- Student
Click Here to complete the Student COVID-19 Self Reporting Form.
First Name * Required
Last Name * Required
Employee ID# * Required
Supervisor's Name: * Required
Email * Required
Enter Email Confirm Email
Primary Phone Number * Required
Last Date You Were on Campus * Required
MM slash DD slash YYYY

Estimate if you're not certain.
Which ACC Campus? * Required
What are you reporting? * Required
- I have been tested, and the result was POSITIVE.
- I have been tested, and the result was NEGATIVE.
Are you fully vaccinated? * Required
- Yes
- No
Additional Comments

Current Students

Future Students

General

Public Safety

Employee COVID-19 Self Reporting Form

Click Here to complete the Student COVID-19 Self Reporting Form.