Self-Reporting Illness Form - Cleveland Community College

First Name *

Last Name *

Student/Employee ID

Email *

Phone *

I am a *

Address *

Street Address City State / Province / Region ZIP / Postal Code

Do you have COVID 19 symptoms (Fever, Fatigue, Body Aches, Cough, Shortness of Breath, New Loss of Sense of Taste or Smell)? *

Yes
No

Have you tested for COVID-19? *

Yes
No

What were your results?

Have you been in close contact with a COVID-19 positive individual within the past 14 days? *

Yes
No

What was the date, time, and location of your last visit on-campus? *

Additional Comments

To better serve you, may we contact your instructor(s) to inform them you may need temporary accommodations in the event you are asked to remain off campus for a specified time period? *

Yes
No