Self Reporting Illness Form

Please fill out the form below if you think you have been exposed to COVID.

Today’s Date:(*)

Invalid Input

First Name(*)

Invalid Input

Last Name(*)

Invalid Input

Date of Birth:(*)

Invalid Input

Banner ID:(*)

Invalid Input

Phone Number:(*)

Invalid Input

Street Address:(*)

Invalid Input

City:(*)

Invalid Input

State:(*)

Invalid Input

Zip Codes:(*)

Invalid Input

Email(*)

Invalid Input

I am a...(*)

StudentFaculty MemberStaff Member Invalid Input

Campus:(*)

Downtown New HavenNorth Haven Invalid Input

Department:

Invalid Input

Who is your supervisor?

Invalid Input

Have you contacted your supervisor?

YesNo Invalid Input

Current Situation:

I tested positive for COVIDSomeone else in the immediate family has COVIDI may have been exposed recently to COVID but tested negative Invalid Input

Date of Symptom Onset:(*)

Invalid Input

Date of COVID Test:(*)

Invalid Input

Date of Vaccination:(*)

Invalid Input

Your Test Results:

PositiveNegative Invalid Input

Acknowledgement: I acknowledge that I have read the above guidance regarding Covid, quarantine, isolation and contact tracing and will not return to campus until date determined by the GCC Covid Coordinator. I will notify Gateway's Dean of Students (students) or my supervisor (employees) of my return date determined by the Gateway Community College Covid Coordinator. I attest that the information provided is true and correct to the best of my ability and understand that any false statements/allegations may be subject to disciplinary action included but not limited to expulsion (student) or dismissal (employee). If you are fully vaccinated (2 weeks or more after the last required vaccination) you may provide proof of vaccination to either the Dean of Student Affairs office or Human Resources.