Covid-19 Self-Report Illness Form - Western Piedmont Community College

Please answer the following health questions as part of our screening for COVID-19.

Date

Name

First Last

Student ID Number

Telephone Number

Reporting Exposure

Have you had close contact (less than 6 feet for more than 15 minutes without a face covering) in the last 14 days with someone diagnosed with COVID-19?

Yes
No

You are no longer required to quarantine and may remain on campus, but required to wear a mask for 10 days from the date of exposure.

If you develop symptoms or test positive, please submit a new report online.

Contact with Someone Tested for COVID-19*

Have you had close contact (less than 6 feet for more than 10 minutes) in the last 4 to 7 days with someone who has been tested for COVID-19?

Yes
No

Date of Synptoms Onset

When did the person you had close contact with start showing symptoms?

Date of Last Contact

When was the last contact you had with this person?

Symptoms

Since you were last at school, have you had any of these symptoms? (Check all that apply)

When did your symptoms start?

Tested for COVID-19

Since you were last at school, have you tested for COVID-19?

Yes
No

Date Tested

Result

Are you fully vaccinated?*

Yes
No

Date of First Vaccination (mm/dd/yyyy)

Date of Second Vaccination (mm/dd/yyyy)

Please share the vaccine that you had:

Johnson & Johnson
Moderna
Pfizer

Have you recovered from a documented COVID-19 infection in the last 3 months?

Yes
No

Covid-19 Diagnosis Date mm/dd/yyyy

Last Date You Were On Campus: