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
- Student
- Faculty
- Staff
- Research Foundation Staff
- Vendor
- Visitor
- Other
Questions
Have you tested positive for COVID-19?*
- Yes
- No
If yes, what date was your COVID-19 test administered?*
MM slash DD slash YYYY
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.
- Yes
- No
If yes, indicate the vaccine you received and the date you received one of the following:*
- Single-dose vaccine (Johnson & Johnson’s Janssen)
- Second dose in the 2-dose series vaccine (Pfizer).
- Second dose in the 2-dose series vaccine (Moderna).
Date*
MM slash DD slash YYYY
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.
- Yes
- No
If yes, indicate when and how this contact occurred.*
Have you physically been on campus during the past 14 days?*
- Yes
- No
If yes, what date were you on campus?*
MM slash DD slash YYYY
On this date, what location(s) did you visit while on campus?*
On the date, were you in contact with anyone on campus?*
- Yes
- No
If yes, indicate who you were in contact with and how this contact occurred.*
Are you currently?*
Check all that apply
- Taking classes at another CUNY campus on E-permit.
- Adjunct teaching at another CUNY campus.
- A student at another CUNY campus.
- A faculty member at another CUNY campus.
- A staff member at another CUNY campus.
- A CUNY consultant or contractor at another CUNY campus.
- None of the above.

COVID-19 Reporting Form

Personal Information

Questions