EmailMeForm
COVID-19 Self Report 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
Email
*
Phone
*
###
-
###
-
####
918 Number
Type
*
Please select
Student
Faculty
Staff
Contractor
Please list all your Face to Face instructors
*
Are you a Student Worker?
*
Please select
Yes
No
Please provide Supervisor Name and Department.
*
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?
Reason for Self-Reporting
*
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.
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
Other Information That Might Be Helpful
