COVID19 Self Reporting Form - Employee

Northeast Texas Community College
COVID-19 Self Report Form
For Employees

Employee Information

Please Select One:

Staff

FT Faculty

Adjunct Faculty

First Name:

Last Name:

Department:

Phone Number:

NTCC Email Address:

Last Date on Campus:

COVID-19 Exposure

Please Select One:

I have symptoms of COVID-19

I have had close contact exposure without a face covering or PPE to someone with COVID-19 symptoms or who tested positive for COVID-19

Other (including testing positive for COVID-19):

Date of onset of symptoms or exposure:

Actions you have already taken (waiting for test results, scheduled doctor's appt, isolating from family members, etc.):

If you have been tested, date of test:

Course Information - For Faculty Only

Please list the courses you are teaching as well as the delivery method:

Course #1:

Title: