COVID Student Reporting Form

COVID Student Reporting Form

This reporting form is for STUDENTS to notify the College if they have been diagnosed with COVID-19 by a medical provider or have been advised to self-quarantine due to a COVID-19 exposure.

COVID-19 Identification Form

Name*
First Last
If you are not self-reporting, what is your relationship to the student?
Student ID #*
Email*
Phone*
College Affiliation*
Nature of Report*
Urgency of Report*
Where did this incident occur?*
please include specific location of suspected COVID exposure
Please provide information regarding additional person(s) believed to have been in close contact with you and could be affected by COVID-19
Close contact is defined as exposure within a 6-foot radius for longer than 15 minutes.
Name of additional person(s) believed to be affected
Is this individual(s) an Iowa Valley student? (this may be Ellsworth, Marshalltown, Grinnell, or Continuing Education)
- Yes
- No
Additional student's email (if known)
Additional student's phone number (if known)
Please provide additional information
Are you currently sick or exhibiting symptoms?*
- Yes
- No
Dates believed to have been in contact with someone affected by COVID-19*
(Please provide calendar dates)
Provide any additional information the College may need to know here.
Statement of Acknowledgement*
I attest that the information provided is true and correct to the best of my knowledge and understand that any false statement or allegations may be subject to the Student Code of Conduct disciplinary actions.

COVID Student Reporting Form

COVID-19 Identification Form

Please provide information regarding additional person(s) believed to have been in close contact with you and could be affected by COVID-19

Please provide additional information