Self Reporting Form

Your Information

Have You Received A Positive COVID-19 Test?*

No

Yes

Tell us about yourself?*

Last Name*

First Name*

Banner ID#*

Phone Number*

McNeese Email Address*

Please Answer The Following

Do you have Symptoms?*

Yes

No

I Have Symptoms (Check all that Apply)

From the CDC: People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Date When Symptoms Started.*

I have received a positive test result

Date of COVID-19 test

Date you received the positive result

Contact Tracing*

Were you in close contact* with student, faculty or staff members for the previous 48 hours?

Close contact: Someone who was within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to specimen collection) until the time the patient is isolated.

Yes

No

Contact Tracing Names*

It is important that we reach out to these individuals to see if they are experiencing symptoms. Please list all individuals that you can remember.

Names of Person

Phone Number

Cowboy Strong

Your Information

Please Answer The Following

I have received a positive test result

Final Questions

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