Student COVID-19 Self Reporting Form

En español: COVID-19 Formulario de autoevaluación

Students, 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.

First Name * Required
Last Name * Required
Student ID# * Required
Current Program of Study * Required
(for example: Nursing, Graphic Design, etc.)
Email * Required
Enter Email Confirm Email
Primary Phone Number * Required
Last Date You Were on Campus - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY

Estimate if you're not certain.
Which ACC Campus? * Required
What are you reporting? * Required
- I have symptoms but have not been tested.
- I have been tested but have not received results yet.
- I have been tested, and the result was POSITIVE.
- I have been tested, and the result was NEGATIVE.
- I have been diagnosed with COVID-19 but have been told that I will not be tested at this time.
- Someone in my household has been tested within the last 10 days for COVID-19.
- Someone in my household has tested Positive for COVID-19.
Additional Comments

Student

Employee

General

Public Safety

Student COVID-19 Self Reporting Form

En español: COVID-19 Formulario de autoevaluación

COVID-19 RESPONSE: STAY UPDATED HERE

SELF-REPORTING FORM: STUDENT | EMPLOYEE

Public Safety

Student COVID-19 Self Reporting Form

En español: COVID-19 Formulario de autoevaluación

COVID-19 RESPONSE: STAY UPDATED HERE SELF-REPORTING FORM: STUDENT | EMPLOYEE

COVID-19 RESPONSE: STAY UPDATED HERE

SELF-REPORTING FORM: STUDENT | EMPLOYEE