COVID-19 Assistance Request or Self-Report Form for Students
Agnes Scott College continues to monitor the spread of the coronavirus and its potential impacts to
the college and to students. Updates, resources, and current information will be posted the ASC
Coronavirus webpage:
Please refer to it for updates.
Our priority is protecting the safety and wellbeing of our students, and offering support during this
difficult time. Please use this form to self-report COVID-19 related diagnosis, exposure, self-
isolation, or quarantine. Or, to indicate support that you may need during this time, so that it can be
routed to the appropriate department on campus. Once completed, please email to
Your Name (First name, Last name): ________________________________________________
Agnes Scott Email address: ________________________________________________________
Phone Number: ___________________________
Student ID Number: _______________________
Have you been diagnosed with COVID-19 by a health care provider?
Yes No Other: __________________________________________
Have you been instructed by a health care provider or public health official to self-isolate or
quarantine because you are experiencing symptoms of COVID-19?
Yes No Other: __________________________________________
Which of the following describes your circumstances? (Check all that apply)
I am experiencing symptoms of COVID-19.
My healthcare provider advised that I self-isolate.
I am self-isolating because of recent travel.
I am immunocompromised and have questions about my health.
I have been tested, but I am waiting for my results.
I have tested positive for COVID-19.
I have not been diagnosed with COVID-19, and am not having symptoms. But, I would like
to request support from the college at this time.
Other: __________________________________________________________________
Please share what type of support from the college would be helpful to you at this time. Check all
that apply.
Communication from Student Health Services regarding a health condition.
Support from ITS.
Communication with Counseling and Psychological Services (CAPS).
Assistance from the Student Emergency Fund.
Food and/or supplies from the Supply Closet
Assistance from Academic Advising and Accessible Education.
Communication from the Office of Student Affairs.
I do not need additional support at this time.
When were you last on campus? Please enter a date: ___________________
Any international or domestic travel within the last four weeks? If so, where?
If you are experiencing symptoms consistent with COVID-19, or had a known exposure or
diagnosis, have you been within 6 feet of ASC students, faculty, or staff in the last 14 days? If so,
please provide the names of those individuals to the best of your recollection. A staff member from
Student Affairs may contact you to learn of your interactions.
Please include additional information about the type of support and/or resources you may need.