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.
  • Email * Required
  • Date Format: MM slash DD slash YYYY
    Estimate if you're not certain.
  • What are you reporting? * Required