If possible, this form should be completed by person experiencing symptoms/tested for COVID-19 or exposed to someone with COVID-19. If impacted person is unable to complete the form, then it should be completed by the instructor or supervisor of the person, or a designated support person.
Date of this Report
MATC ID Number:
Your affiliation with College:
Mobile Phone Number:
Nature of this report:
Date you were last physically present on a campus and/or participated in an in-person college related activity?
When were you diagnosed?
Were you given a treatment plan?
What was the treatment plan? (e.g. quarantine, hospital, home care, etc.) *
Have you completed the treatment plan and been release by a healthcare provider?
When do you complete complete treatment or will have documented release by a healthcare provider?
Where were you on campus ? Please be specific as to the buildings and rooms.
Reference to a map is located HERE
Who did you interact with while on campus? Please be specific.
When did you begin exhibiting symptoms?
Have you contacted a healthcare provider in regards to your symptoms?
Have you or are you planning on being tested?
Date of Test
Were you in close contact (as defined by CDC)?
You were within 6 feet of someone who has COVID-19 for a total of 15 minutes or more You are room matesYou provided care at home to someone who is sick with COVID-19You had direct physical contact with the person (hugged or kissed them)You shared eating or drinking utensilsThey sneezed, coughed, or somehow got respiratory droplets on you
Last date believed to have been in contact with someone exposed to COVID-19
Have you been contacted by the local health department to self-quarantine?
Instructed date of quarantine ending?
I acknowledge by submitting this form that I am asked to stay off campus or from participating in any college in-person activity until I receive written approval from the College prior to returning to campus.
Enter initials to acknowledge:
By submitting this form, I understand that I will be contacted by a member of MATC for additional guidance and support for a safe return to campus.
I attest the information provided is true and correct to the best of my ability and understand that any false statements/allegations may be subject to disciplinary actions including but not limited to expulsion or termination.