COVID19 Self Reporting Form - Student

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

Student Information

Please Select One:

NTCC Student

TAMUT Student

First Name:

Last Name:

Student ID:

Phone Number:

Email Address:

Academic Program:

Do you live in the NTCC Dorms?

Yes

No

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:

Are you vaccinated against COVID-19? (Both doses if receiving a two dose regiment - if not, answer NO):

Yes

No

Prefer not to answer

Course Information

Please list your courses and NTCC will contact you faculty regarding your absence due to self-isolation:

Course #1:

Title:

Instructor: