Student COVID-19 Self Reporting Form

-En español: COVID-19 Formulario de autoevaluación

-Looking for the daily screening ACC SAFE app? Click here.

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.

Note: Please do not submit this form more than once. After the first submission, our Health Educator will follow up with you and update your status as needed.

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
Last Date You Were on Campus * Required
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
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

Student COVID-19 Self Reporting Form

-En español: COVID-19 Formulario de autoevaluación

-Looking for the daily screening ACC SAFE app? Click here.

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