NJIT COVID-19 (coronavirus) Self-Reporting Form

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Email *

What is your first name?

What is your last name?

What is your NJIT email address?

What is the best telephone number at which to reach you?

Which is your primary NJIT affiliation?

Undergraduate Student

Graduate Student

Faculty Member

Staff member

Visitor

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Have you been in contact with someone who has a confirmed or presumptive case of COVID-19 (coronavirus)?

Yes

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If you have been in contact with someone who has a verified or presumptive case of COVID-19 (coronavirus), when did that contact occur?

YYYY

Have you contracted a confirmed or presumptive case of COVID-19 (coronavirus)?

Yes

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Have you traveled to a country with a CDC Level 2 or 3 Warning for coronavirus outbreak during the last 14 days? The latest CDC advisories can be found at https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html.

Yes

Clear selection

On what date did you return to the United States?

YYYY

Have you been in contact with someone who has traveled to a country with a CDC Level 2 or 3 Warning for coronavirus outbreak during the last 14 days?

Yes

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Submit

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