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.

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) in the 48 hours prior to when symptoms onset or 48 hours prior to a positive test?:  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 What campus do you attend? Please mark any campuses you have attended in the 48 hours prior to when symptoms onset or 48 hours prior to a positive test.:*  Canton Macomb Havana Rushville 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 48 hours prior to when symptoms onset or 48 hours prior to a positive test.:*  Have you been contacted by a local health official and told to quarantine?:  Yes No If yes, what County Health Department contacted you?:  Are you fully vaccinated?:*  Yes No If yes, have you previously provided proof of vaccination through the COVID incentive?:  Yes No If no, please attach picture of vaccination card.:     Is there anything else you would like to add?:  If you will miss class or work, please contact your faculty members and/or your supervisor Supporting Documentation If you have received documentation from a local health official advising you to quarantine or isolate, please attach that information here. 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.:*