COVID-19自我报告表格 此表格应由学生使用, 客人, and employees (to include contractors and vendors) who are reporting that they have received a positive test result for the coronavirus, 是否出现病毒症状, or have been exposed to a person who has symptoms or a positive test result for COVID-19. Please understand by completing this self-reporting form or speaking to a college employee we are not providing medical advice. You should check with your primary medical provider for question or concerns specifically related to your health. 一旦您的表单被提交, a member of the CTC COVID-19 Response Team will follow up with you. 今天的日期 日期格式:MM / DD / YYYY 名字 第一个 最后的 电话电子邮件 角色:*选择所有适用的.学生雇员/联邦勤工俭学学生来宾或申请人学生证号码*班级或工作地点:*选择所有适用的.卡尔·帕特里克·霍尔W.G. Hartline建筑图书馆莱特健康科学大楼A.P. 高迪大厦(西翼)经济发展-交通大道烹饪艺术-直接服务，汉密尔顿道刑事司法-便携D具体位置:*提供特定的办公室/教室/实验室参观.最后到校日期* 日期格式:MM / DD / YYYY 涉及党Please add the names of campus community members that you have had close contact with according to the definition of the Department of Public Health. 密切接触包括: • 与COVID-19患者一起生活或照顾患者; • Being within 6 feet of a sick person with COVID-19 for about 15 minutes (no matter whether a mask was worn or not); OR • Being in direct contact with secretions from a sick person with COVID-19 (e.g.、被咳嗽、接吻、共用餐具等.). 与症状相关的问题*In the following questions we would like to gather more information about your illness and your activities after you became sick with or exposed to COVID-19 to help stop the spread. 您目前是否有COVID-19的症状?是的No症状发生日期如果您出现COVID-19症状, please indicate below the date the symptoms first started (mm/dd/yyyy). 日期格式:MM / DD / YYYY 无标题的If you have had symptoms, have you seen a medical provider? 如果有，你得到了什么指示? 同意*Please check the box below to acknowledge understanding of the statement below: 我理解 that if I am experiencing COVID-19 related symptoms, 我生病时不应该来学校. If I am an employee, I should also notify my supervisor in addition to completing this form. 如果症状变得严重，请就医. 严重的症状包括呼吸困难, 胸部持续疼痛或压迫, 混乱, 不能清醒或不能保持清醒, 或者嘴唇或脸发青. 我理解.*与COVID-19测试结果相关的问题*您是否收到COVID-19检测阳性的通知? 是的No无标题的If you answered yes to the previous question: when were you tested, 你在哪里接受的测试?, 你什么时候收到成绩的, 你得到了什么指示?同意*Please check the box below to acknowledge understanding of the following: 我理解 that if I received a positive COVID-19 test result, I should not come to campus. 我理解.*与你与他人接触有关的问题*Have you been exposed to someone sick with COVID-19 or test positive for COVID-19, as described by the Georgia Department of Public Health, 下面? You generally need to be in close contact with a sick person to get infected. 密切接触包括: * 与COVID-19患者一起生活或照顾患者; * Being within 6 feet of a sick person with COVID-19 for a cumulative of 15 minutes or more within a 24-hour period, (no matter whether a mask was worn or not); OR * Being in direct contact with secretions from a sick person with COVID-19 (e.g.、被咳嗽、接吻、共用餐具等.). 是的No日期If you were exposed to COVID-19 (as per the GA Dept of Public Health definition), please indicate below the date of your last exposure (mm/dd/yyyy). 日期格式:MM / DD / YYYY 无标题的If you were exposed to COVID-19 (as per the GA Dept of Public Health definition), 请描述一下你的暴露情况同意*Please check the box below to acknowledge the understanding the following statement: 我理解 if I answered yes to being exposed to COVID-19, I should not come to campus. I should self-isolate and make the appropriate notifications to the CTC COVID-19 Response Team at covid19response@columbustech.或者我的导师. 我理解.*问题 Associated With Others That May Have Been Exposed to You (for contact tracing purposes)*Have others been in close contact with you 48 hours before your symptom onset OR your date of COVID-19 testing? NOTE: The Georgia Department of Public Health describes 关闭 联系 to generally mean you were: * 与COVID-19患者一起生活或照顾患者; * Being within 6 feet of a sick person with COVID-19 for a cumulative of 15 minutes or more within a 24 hour period, (no matter whether a mask was worn or not); OR, * Being in direct contact with secretions from a sick person with COVID-19 (e.g.、被咳嗽、接吻、共用餐具等.). 如果你还没有这样做, please list the names of any close contacts for campus community members in the section near the top of this form labeled 涉及党. 是的，我一直在与其他人密切接触. I have included the names of any campus community member I have had close contact within the section above labeled "涉及党".No, 我没有与他人密切接触, 校内或校外, 正如乔治亚州卫生部所描述的校园就业*你在学校工作吗? Please understand that if you are asked to self-quarantine you may be able to continue working remotely. 是的No无标题的*如果你在校园里工作(包括学生就业), who is your direct supervisor? 无标题的*如果你在校园里工作(包括学生就业), please indicate below the last date you reported to work (mm/dd/yyyy). 在线赌博感谢您花时间填写此表格. The Information provided will help to protect our campus community. Please share any questions of concerns related to COVID-19 and your enrollment/employment. You may contact the CTC COVID-19 Response Team at covidresponse@vespaeastside.com 作者 塔拉歪斜的
