COVID Self Reporting Form

By selecting this box, you confirm you will not return to the Victoria College campus until your quarantine period is over.

I have tested for COVID-19

I am Experiencing COVID-19 symptoms

I have been in close contact with someone who is showing COVID-19 symptions or who has tested positive for COVID-19

I have been on campus since since the onset of my symptoms or exposure to COVID19

Check your Victoria College Email to confirm correct submission of data. This email will contain your return to campus date. Your instructors will be notified of your submission.

When were you tested for COVID-19? *

*

I tested positive

I tested negative

I have not received results - You do NOT need to resubmit once results are obtained

When did you begin experiencing symptoms? *

Headache

Diarrhea or vomiting

Fatigue

Muscle or body aches

Cough

Congestion or runny nose

Fever and chills

Shortness of breath or difficulty breathing

Other

When were you exposed to COVID-19? *

We maintained social distance of 6 feet or more.

I was wearing a facial covering.

We remained in close contact for 15 minutes or less.

Where were you exposed to COVID-19?

Mo	Tu	We	Th	Fr	Sa	Su
	1	2	3	4	5	6
7	8	9	10	11	12	13
14	15	16	17	18	19	20
21	22	23	24	25	26	27
28	29	30

COVID-19 Self-Reporting Form

Thank you! Your instructors will ONLY be notified if you are asked to quarantine.

Enter your V#:	If you don't know your V#, you can look it up here.
Enter your birth date (mm/dd/yyyy):