COVID-19 Reporting

*** This is NOT the daily Campus Sign In form, please click here to go to that form. ***

ATTN: ONLY COMPLETE THIS FORM FOR THE FOLLOWING REASONS:

Recently (past three weeks) been tested for COVID-19
Are experiencing symptoms of COVID-19
Have been in close contact (within 6' for 10 minutes or longer) of someone who has tested positive for COVID-19 in past three weeks

Please complete this form if you have recently been tested for COVID-19, are experiencing symptoms of COVID-19, or have been in close contact (within 6' for 10 minutes or longer) of someone who has tested positive for COVID-19.

If an employee or student is not able to complete this form, their faculty member, supervisor, or another individual may complete the form on their behalf.

The following individuals have been appointed as Wellness Contacts for the College. The appropriate Wellness Contact will call or email you regarding the information provided on this form. All information shared with Wellness Contacts, or other faculty/administrators of the College, will be kept strictly confidential.

Student Wellness Contact
Denise Walker
Phone: 423-323-0211
Email: dpwalker@NortheastState.edu

Employee Wellness Contact
Megan Jones
Phone: 423-323-0226
Email: majones@NortheastState.edu

Please select whether you are completing this form as (or for) an employee or student.

Employee
Student

Please enter the following employee/student information: (* denotes a required field)

First Name: *
Last Name: *
Banner ID (if known):
Phone Number: *
Alternate Phone Number:
Email Address:
First Date of COVID-19 symptoms:	(MM/DD/YYYY format)
Date of COVID-19 test:	(MM/DD/YYYY format)
If you have been tested for COVID-19, what were the results?
Last Date of Close Contact to a person who has tested positive for COVID-19 (within 6' for 10 minutes or longer):	(MM/DD/YYYY format)
County of Residence: *
Last Date on Campus:	(MM/DD/YYYY format)
Comments: