Student COVID-19 Report Checklist Form

STUDENT COVID-19 REPORT CHECKLIST

The information provided below is collected for assessment by the JCC COVID-19 Emergency Response Team

and is treated as confidential, shared on an as-needed basis, only.

* Indicates Required Field (failure to answer all required fields may result in a failed form submission)

Type "N/A" in any fields that do not apply to your situation.

*Have you recently been in close contact with someone who has tested positive for COVID-19?YesNo

*If so, provide an explanation of the close contact situation.

*List the date of last contact (MM/DD/YYYY).

*Does the close contact live in the same house as you?YesNo

*What date did they test positive (MM/DD/YYYY)?

*Are you or have you been experiencing any symptoms of COVID-19?YesNo

*If YES, what are/were your symptoms?

*What date did your symptoms begin (MM/DD/YYYY)?

Please include whether your symptoms started in the morning, afternoon, or evening.

*Have you been vaccinated against COVID-19?YesNo

*If you have been vaccinated, which vaccine? Please include ALL dates that you received a COVID-19 vaccine shot.

*Have you been tested for COVID-19?YesNo

If you selected YES:

*WHEN and WHERE were you tested? Please include the Date (MM/DD/YYYY), Time, and Testing Site/Location.

*Have you received your results?Yes No

Please email a copy of your test results to jccsafety@johnstoncc.edu, displaying your name, the test date, and testing site/location.

*What were the results from your COVID-19 test?

If you selected NO:

*Do you plan on getting tested?YesNo

*What date do you plan on getting tested (MM/DD/YYYY)?

Prepare to get tested for COVID-19 at least 5 days after any onset of symptoms or exposure to another COVID-positive person.

*Have you notified ALL of your instructors?YesNo

IMPORTANT: It is highly recommended that you keep in communication with your instructors!

*When were you last on campus? List date (MM/DD/YYYY) and time(s).

*Please list ALL buildings, department/service areas (i.e., Student Success Center, Library, Bookstore, computer labs), offices, classrooms, restrooms, etc., you entered while on campus during the past week, including when and approximately how long you were in each area.

*Were you and others wearing face coverings and practicing social distancing while on campus during the last week?YesNo

NOTE: The Johnston County Public Health Department defines “close contact” as being less than 6 feet from another person for a cumulative time of 15 minutes or more, regardless of wearing masks.

*Did you have close contact recently with anyone while last on campus?YesNo

*Please explain, including name(s) of individual(s). If you do not remember full names, please provide as much information as possible to assist with identification.

*If applicable, who were the students sitting next to you on either side, behind you, and in front of you during the classes you attended?

Include any additional comments that you would like to add to provide clarity regarding the situation, to include

vaccine details.

Please also provide the best phone number you can be reached at, if needed. If you need more space,

include additional details within an email to jccsafety@johnstoncc.edu or COVIDEmergencyResponseTeam@johnstoncc.edu.

Additional Information

REMINDER: Before you click "Submit" make sure all required (*) fields have been answered.

Type "N/A" in any fields that do not apply to your situation.

Be prepared to submit a copy of your test result and proof of vaccination (if applicable). If neither are readily available, please follow up as soon as possible once results are known and/or documentation is located.

Do not schedule a test any sooner than five (5) days after onset of symptoms or exposure to COVID-19.