Fillable Form 1: CAMPUS LEVEL CONTACT TRACING- EASY CHECK (East Los Angeles College)

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Form 1: CAMPUS LEVEL CONTACT TRACING- EASY CHECK (East Los Angeles College)

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The Form 1: CAMPUS LEVEL CONTACT TRACING- EASY CHECK (East Los Angeles College) form is 1 page long and contains:

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  • 12 check-boxes
  • 22 other fields

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File type: PDF

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1
CAMPUS LEVEL CONTACT TRACING- EASY CHECK LIST
. Date Campus
___________________ __ ___________________________________________
2. Name ID#
:
Student Employee Visitor
3. Home Address:
4. Contact Phone # Email
5. If Employee, work location (building(s)/room#)
6. If Student, semester currently enrolled in 20
7. If Visitor, name of company and purpose
8. Nature of self-report: POSITIVE SUSPECTED EXPOSURE - TO COVID-19
9. Has individual tested for COVID-19?
YES Test Date: NO If NO, when is test date scheduled:
10. COVID-19 test results Positive [result date ] Negative [result date ]
11. Last day on campus If person was not on campus, please stop here.
12. PPE worn on campus:
13. Was there “close contact*” with anyone on campus? Yes No
14. Who and where did individual come in “close contact*” with while on campus?
*Close contact is less than 6 feet for more than 15 minutes over a 24-hour period.
15. List symptoms, if any
16. Date self-isolation began
ADDITIONAL NOTES:
Instructions for submission: Before submitting, be sure to report cases to your campus President. Once this form is
c
omplete, submit to macdonne@elac.edu.
East
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Form 1: CAMPUS LEVEL CONTACT TRACING- EASY CHECK (East Los Angeles College)

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Completed 29 January 2021

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