MCAD COVID-19 Exposure Report Form
Thank you for contacting MCAD about your COVID-19 related concerns. Information shared in this survey will be kept confidential within the MCAD Stay Safe Care Team and used only for follow up and contract tracing. Someone from the MCAD Stay Safe Care Team will contact you for follow up as quickly as possible for any additional questions and/or to share any resources or information you may need.

PLEASE NOTE: If you are not feeling well, please stay home, stay masked, and maintain 6' physical distance between yourself and others until you have been contacted, especially if you have any of the following symptoms: Fever 100.4 F, fatigue, tiredness, new muscle pain for no known reason, headaches, sore throat, a new and persistent cough, loss of taste or smell, etc.

If you are experiencing symptoms such as bluish lips, difficulty breathing, pain/pressure in the chest, new/significant confusion, or the inability to wake up or stay awake, call 911 or seek advanced medical care immediately.

Sign in to Google to save your progress. Learn more
Email *
Name: *
Address: *
Email: *
Phone Number: *
Birthdate: *
MM
/
DD
/
YYYY
Are you fully vaccinated (two weeks past your last shot)? *
What brand of vaccine did you receive? *
Do you know what date you received your last vaccination shot?
MM
/
DD
/
YYYY
Have you received a "booster" shot associated with the initial vaccine? *
What was the date of your booster vaccine?
MM
/
DD
/
YYYY
What type of booster did you receive? *
Are you experiencing any of the following symptoms?(select all that apply) *
Required
If experiencing symptoms, when did they begin (date/time)?
If you were a close contact of a COVID positive person, do you know who, where, or when? *
Were you on the MCAD campus or buildings 48 hours prior to the onset of symptoms? If YES, please describe in the following question. *
Have you interacted with any MCAD community members off campus 48 hours prior to the onset of symptoms or within the timeframe of the possible exposure? If YES, please describe in the following question.
Clear selection
If you have been on campus in the past 48 hours before symptoms appeared, please list the location(s) you visited, date, time, and any MCAD community members you may have interacted with where the 6' physical distancing wasn't maintained and/or where the interaction was longer than 15 minutes. Please be as specific as possible. If not applicable, please indicate "not on campus". *
Have you recently participated in any 'high risk' activity where COVID-19 exposure may have occurred (such as party, sports, choir, bar, or any other large social gathering)? *
If you believe you have participated in a 'high risk' activity, please indicate the date/time,  location, and as many details as possible. If you have not, please indicate 'no known high risk activities'.   *
Have you been tested for COVID-19? *
Have you been contacted by the Minnesota Department of Health (MDH) related to COVID-19? *
What additional resources would you like more information about? *
Required
Is there anything else that would be helpful for you at this time?
Is there anything that was not asked as it relates to your COVID-19 concerns that should have been asked?
What is your position type at MCAD? (select all that apply) *
Required
Is there anything else you feel the MCAD Stay Safe Care Team should know?
I understand that an MCAD Contract Tracer will contact me about this form. *
Required
I understand that an MCAD Contract Tracer may need to contact other MCAD community members as it relates to any possible on campus exposure to COVID-19. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of MCAD. Report Abuse
Google Forms