Repor�ng Form for Confirmed Cases of COVID 19
The informon requested below will be used to inform the College Administraon of poten
exposure of conrmed cases of COVID-19 at Capital Community College, and it may be
shared with the local Department of Public Health. Your report and ppon is voluntary, but it is
l to the College’s eorts to control the spread of COVID-19 at the College and within the
community. Although this form requests your name and other personally idenable informon,
that informon may be shared only with the Department of Public Health.
By providing this informon to the College, I consent to its use as described above.
Please email emiranda@ccc.commnet.edu with any quesons.
Have you tested pove for COVID-19?
Where was the test performed?
Check one: Student Employee
(ex: @ 00815719)
What date was the test performed?
What date did you receive the test result?
What date did you begin to experience symptoms?
What date were you on our campus?
Which building(s) and room(s) were you in?
Were you in close contact (within 6 feet or closer, for more than
15 minutes) with anyone at CCC during thme?
