COVID-19 Student Self-Identification COVID-19 Identification Form Name(Required) First Last If you are not self-reporting, what is your relationship to the student? Student ID #(Required) Email(Required) Phone(Required)College Affiliation(Required)Ellsworth Community CollegeMarshalltown Community CollegeIowa Valley GrinnellIowa Valley Continuing EducationNature of Report(Required)Confirmed COVID-19 CasePotential COVID-19 CaseNotification of Self-QuarantineNotification of Medical QuarantineUrgency of Report(Required)NormalCriticalFor information onlyWhere did this incident occur?(Required) please include specific location of suspected COVID exposurePlease provide information regarding additional person(s) believed to have been in close contact with you and could be affected by COVID-19Close 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 informationAre you currently sick or exhibiting symptoms?(Required) Yes No If yes, when did these symptoms start? Dates believed to have been in contact with someone affected by COVID-19(Required) (Please provide calendar dates)Are you fully vaccinated? Have you received the 2-shot series of Pfizer/Moderna or 1-shot J&J? Yes No Have you received a Booster shot? Yes No Provide any additional information the College may need to know here.Statement of Acknowledgement(Required) 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.