This form is for faculty, staff, and/or students to notify Gateway Community College of change in health status related to COVID-19 (Coronavirus)


Contact Information

       
Name
Banner/NetID
Date of Birth
Calendar
Phone #
(-
Street
Email Address
    City/Town
State

Your College Affiliation

I am a student enrolled in classes that meets at: 

Campus (Check all that apply) Program/Site Last day on ground Do you need assistance contacting your instructors?:



Calendar
Calendar
 

 

   
Calendar
 

 

I am a Gateway Employee (Check one):

Employee Type Department Do you need assistance contacting your supervisor?:


 
 

Current Situation



Date of symptom onset:
Calendar
   
Date of exposure:
Calendar
Relationship to individual:
 
 
 
Test Date:
Calendar
Test Type:
Test Results:
   
Other (Specify)

Please provide information regarding symptoms you are currently experiencing, actions taken, and if any assistance is needed from GCC. 


AKNOWLEDGEMENTS:



Date:
CalendarNow