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Student COVID-19 Self Reporting Form
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.
Are you a student or employee?
*
Required
Student
Employee
Click Here
to complete the Employee COVID-19 Self Reporting Form.
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
Choose your student status:
*
Required
I come to campus for at least one class
Online only
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.
Please list the names of your instructors and class names.
*
Required
Which ACC Campus?
*
Required
Main Campus (Haw River)
Dillingham (Burlington)
Both Campuses
Other (please comment at end of form)
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.
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COVID-19 RESPONSE:
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SELF-REPORTING FORM:
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COVID-19 RESPONSE