COVID19 Self Report Form - COVID and Alerts - South Georgia State College

COVID-19 Self Report Form: South Georgia State College

THIS FORM AND REQUIREMENT IS NO LONGER ACTIVE. PLEASE DO NOT USE THIS FORM.

To ensure that we can provide support/resources to students who have been potentially exposed to or tested positive for COVID-19, we request that individuals (or a designee) complete the below form. This information will also assist SGSC and public health officials with monitoring the incidence of cases occurring in our communities.

We are committed to ensuring that your submission remains confidential in accordance with applicable law and will only be used to provide support and resources. If an individual is diagnosed with a confirmed case, our public health partners will work to make sure those who have been exposed are contacted.

What does to be fully vaccinated mean? In general, people are considered fully vaccinated:

2 weeks after their 2^nd dose in a 2-dose series, such as the Pfizer or Moderna vaccines
2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine

Please fill out the form below. Required fields are indicated with a * symbol. Thank you.

Personal Information

Full Name *

First Name

Last Name

Date of Birth *

Phone Number *

Email *

Campus *

Student ID or 988 #:

Are you a Commuter Student? *

Yes

Are you a Residential Student?

Yes

County Where You Are Currently Residing: *

City or Residence Hall Where You Are Currently Residing:

Reason for Self Reporting:

Are you fully vaccinated?

Yes

Estimated Date of Your Exposure Write in the date or unknown

Date of Your Noticeable Symptoms Write in the date or no symptoms

Date of Your COVID-19 Screening Test Write in date or not applicable

Location of Your Testing Site * Write in the testing site or not applicable:

Last Date You Were Physically On Campus:

Other Info that May Be Helpful: