COVID-19 Reporting Form

Personal Information

Name*

First Last

Empl ID*

Your Empl ID is an 8-digit number.

Telephone Number*

Email*

Affiliation:*

Check all that apply

Have you tested positive for COVID-19?*

If yes, what date was your COVID-19 test administered?*

Are you fully vaccinated against COVID-19?*

As per the CDC, people are considered fully vaccinated

Two weeks after a single-dose vaccine (Johnson & Johnson’s Janssen).
Two weeks after their second dose in 2-dose series vaccines (Pfizer or Moderna).
At the time specified in either the FDA licensure or World Health Organization (WHO) approval, after the final administration of any other vaccines.

If yes, indicate the vaccine you received and the date you received one of the following:*

Date*

Have you had any known close contact with a person confirmed or suspected to have COVID-19 in the past 14 days?*

As per the NYC Department of Health, close contact defined as:

Someone who has been within 6 feet for at least 10 minutes over a 24-hour period of someone who has COVID-19.
In most cases, all people living with someone who has COVID-19 are close contacts.
Close contacts may also include home health aides, coworkers, classmates, or friends or families you have spent time with.

If yes, indicate when and how this contact occurred.*

Have you physically been on campus during the past 14 days?*

If yes, what date were you on campus?*

On this date, what location(s) did you visit while on campus?*

On the date, were you in contact with anyone on campus?*

If yes, indicate who you were in contact with and how this contact occurred.*

Are you currently?*

Check all that apply