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Covid-19 Self-Reporting Form
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* Indicates required question
Name:
*
Your answer
Contact Number:
Your answer
Student ID #:
*
Your answer
Are you a dorm or commuter student or employee?
*
Dorm
Commuter
Employee
Date of positive test.
*
MM
/
DD
/
YYYY
List the campus you attend: (Ellisville, Clarke, Jasper, Wayne, Greene, Advanced technology)
*
Your answer
date of symptoms
*
MM
/
DD
/
YYYY
List direct contacts below: (Those within 6 feet for more than 15 minutes- up to 48 hours prior to onset of symptoms).
*
Your answer
List any extracurricular activities/clubs/sports you are involved in at Jones.
*
Your answer
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