North Central College Logo

COVID-19 Reporting Form


North Central College has an important role in slowing the spread of diseases, and protecting vulnerable students, staff, and faculty to help ensure a safe and healthy learning environment. Reporting COVID-19 contact, positive tests, and/or symptoms supports our goal of providing a safe campus by working to prevent the spread of the virus.

To ensure that NC can provide support and resources to faculty, staff, and students with probable or confirmed COVID-19 cases, the College is requesting that individuals (or a designee) complete the form below. This information will also assist NC and public health officials with monitoring the number of cases occurring in our community.

The College is committed to ensuring that your submission remains private and only utilized as a means to provide support and resources. All information collected will only be routed to campus officials with a legitimate need to know. A COVID-19 Contact Tracer & Case Manager may make contact with you post your submission.

Your submission is not a substitute for medical advice/care; if you are in medical distress, please call 911. For more information about the College’s response to COVID-19 please visit NC’s COVID-19 Updates web page.

Direct self-reports are highly preferred. Per the #TogetherNC pledge, all faculty, staff, and students are required to submit a report when they are aware of someone who has tested positive, is experiencing symptoms, or has been exposed to COVID-19, who has not self-reported.

Reporter Information

Impacted party throughout this form is defined as the North Central individual with COVID-19 exposure, symptoms, and/or a positive COVID-19 test result. If self-reporting, YOU are the impacted party, not the person to which you were exposed. To help ensure thorough follow-up, please provide as much information as possible.

 
Enable additional features by logging in.
Learn more
Name of person completing this form
Learn more
e.g. faculty, staff, student, guest/visitor
Learn more
Phone number of person completing this form
Learn more
E-mail of person completing this form
This field is required.
Learn more
If self-reporting YOU are the impacted party.

Name of Individual who is Positive/Probable/Symptomatic or Physical/Close Contact of COVID-19

If you are self-reporting and have provided information above, please duplicate the information in this section. If you are reporting on behalf of another, please list the name of the individual with a probable/confirmed case, and/or individual who has had contact with an someone with a confirmed positive COVID-19 case. Include as many of the listed fields as possible. For individuals unaffiliated with the College, who have been on campus, please list a Drivers License number in the block labeled ID Number, if available.

Involved party 1

Questions

Definitions
  • Impacted party North Central individual with COVID-19 exposure, symptoms, and/or a positive COVID-19 test result. If self-reporting, YOU are the impacted party, not the person to which you were exposed.
  • Isolation Used to separate a person with COVID-19 symptoms, someone who has tested positive for COVID-19, or a probable case, from those who are healthy. Isolation restricts the movement of the person to help stop the spread of the virus. Isolation lasts 10 days as long as other criteria are met.
  • Quarantine Used to separate and restrict the movement of a person without symptoms who may have been exposed to a confirmed or probable case. Quarantine is used to decrease the spread of the virus. Individuals are quarantined for 14 days from the date of the exposure.
  • Confirmed Case Someone who has had a positive test, laboratory confirmation that they have COVID-19. Someone who can infect others.
  • Probable Case Someone who has symptoms of COVID-19 and a known COVID-19 exposure but has not had laboratory confirmation.
  • Physical Contact Refers to anyone who has had physical contact with a confirmed or probable case.
  • Close Contact Refers to someone who has been within 6 feet of a case or probable case for 15 minutes or longer.
  • Proximate Contact Refers to someone who was more than 6 feet away from a confirmed or probable case for at least an hour in the same enclosed space (i.e. classroom, workspace).

What is being reported for the impacted party?(Required)
This field is required.
This field is required.
This field is required.
If you have received a positive test, were you tested through the North Central College testing process?
This field is required.
This field is required.
Please list symptoms being experienced, if applicable.(Required)
You must make at least one selection.
This field is required.
This field is required.
Has the impacted party traveled recently?(Required)
This field is required.
The impacted party is currently(Required)
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.
I understand and agree to pertinent information related to this report being shared with relevant campus and health department staff members in order to maintain the health and safety of the campus community.(Required)
This field is required.

Supporting Documentation

Upload any relevant documentation such as test results, medical provider documentation, etc. Test results should include your full name, collection date, test type, and clearly indicate the results of the test. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission