COVID-19 Positive or Suspected Case Report

This form is for members of the Spoon River College community (students, faculty, and staff) to report confirmed or suspected cases of COVID-19.

You are strongly encouraged to fill out this form if any of the following apply to you:

• You have been diagnosed with COVID-19
• You have been referred for testing or told by a health care provider that you have a suspected case of COVID-19
• You have come into close contact (closer than 6’ for more than 15 minutes) with someone who has a confirmed case of COVID-19
• You live with someone who had or currently has a confirmed or suspected case of COVID-19
• You have been told to self-isolate or quarantine by a medical provider or public health authority
• You are a faculty or staff member and a student reported to you that they meet any of the criteria above

Any students, faculty members, and/or staff who feel they may have Novel Coronavirus Disease 2019 (COVID-19), or may have been exposed to someone who has COVID-19, should consult their primary care physician. If your symptoms are severe, go now to a clinic or hospital or call 9-1-1. Click here for a complete list of symptoms, and additional information on seeking medical attention, from the Centers for Disease Control and Prevention (CDC), COVID-19 symptoms.

Please note: The College may be obligated to notify local public health authorities of any positive cases of COVID-19 of which it is aware.

Following a COVID-19 related absence, see how to return by viewing our Return to School/Work Flowchart.

Upon receipt of this form, College staff will follow-up with the individual referred in order to check in with them, gather additional information to assist with contact tracing, assess their needs, and communicate appropriate return to school/work protocols.

 COVID-19 Positive or Suspected Case Form

Your Full Name:*  Your Phone:  Your Email:  Affiliation with Spoon River College:  Spoon River College ID#:  Are you reporting for yourself or are you a faculty or staff member and a student reported to you that they meet any of the criteria above?:  Self-reporting Bystander-reporting Bystander Reporting Please fill out as much information as you can about the student to whom which this report concerns. Full Name:  Phone:  Email:  Spoon River College ID#:  Additional Questions Have you or has this individual had or ever reported a positive COVID-19 test?:*  Yes No Unsure Have you or the individual been tested yet, and/or are they planning to be?:*  Yes No Unsure If planning to test, what date?:  Date Are you or this individual currently experiencing COVID-19 symptoms?:*  Yes No Unsure What was the date of onset of symptoms?:*  Date Have you or this individual been in close contact with any member of the SRC community (student,faculty or staff) within the last 14 days?:  Yes No If so, please list any in-person classes or meetings attended or taught, as well as the names of any other SRC-affiliated individuals that you or this individual might have come into contact with (friends, teammates, etc.):  When was the last date you were on campus?:  Date Have you or this individual missed, or will miss class or work at SRC as a result of a confirmed or suspected case of COVID-19?:*  Yes No Where on campus have you or the individual visited prior to onset of symptoms or positive test? Be specific in classroom numbers and/or office names. Type N/A if you or this individual has not been to campus in the last 14 days.:*  If you will miss class or work, please contact your faculty members and/or your supervisor Supporting Documentation In cases where you are requesting accommodations due to illness, please include proper medical documentation affirming diagnosis.Supporting documentation attachment 1:     Supporting documentation attachment 2:     Supporting documentation attachment 3:     If you have any additional information, please list below.:  Help us prevent spam reports.:*