EmailMeForm
Return to Work/Class Form
To ensure that we can provide support/resources to faculty, staff, and 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 ABAC 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.
Name
*
First
Last
918 Number
Email
*
Phone
*
###
-
###
-
####
Type
*
Please select
Student
Faculty
Staff
Contractor
Campus/Site Location
*
Tifton
Bainbridge
Moultrie
Blakely
Donalsonville
Do you live on campus?
*
Please select
Yes
No
If you do not live on campus, in what city do you currently reside?
*
Did you complete the COVID-19 Self Report Form?
*
Please select
Yes
No
Please select the "Reason for Reporting" that you put on the COVID-19 Self Report Form.
*
Please select
I have been potentially exposed to a case of COVID-19, but I have not been tested.
I have been potentially exposed to a case of COVID-19, and I have been tested and am awaiting results.
I have symptoms of COVID-19, but I have not been tested.
I have the symptoms of COVID-19, and have been tested and am awaiting results.
I have tested positive for COVID-19.
I don’t remember the reason I reported
True/False: “I have completed my isolation period and am returning to campus?”
*
Please select
True
False
Please tell us why you did not complete the isolation period:
*
Estimated Date of Exposure
MM
/
DD
/
YYYY
Date of Noticeable Symptoms
MM
/
DD
/
YYYY
Date of COVID-19 Screening Test
MM
/
DD
/
YYYY
Last Date You Were Physically On Campus
*
MM
/
DD
/
YYYY
Test results
*
Please select
Negative
Positive
Inconclusive
I was not tested
Are you currently having any of these symptoms? (check all that apply)
*
Yes
No
N/A
Fever ¬> 100.4 F
Cough
Shortness of Breath
Other Symptoms/Information That Might Be Helpful