Employee COVID-19 Reporting

Please indicate your primary work site:*

De Anza College

Foothill College

Central Services

Are you reporting a positive COVID test result, COVID symptoms or an exposure or close contact with someone who’s had a positive test result?*

Positive COVID Test Result

Close Exposure to Some With COVID

I’m experiencing COVID symptoms but have tested negative or haven't had a test yet

Was the test PCR (administered by a health care professional, for which you had to wait a period of time for the results) or antigen (a home test or one performed by a health care professional, for which you received immediate results)

PCR

Antigen

Both

Date you took the PCR test

Date you received the PCR test results

Date of antigen test results

Do you know when you might have been exposed?

Have you scheduled a PCR test? If so, please indicate the test date. If not, leave blank.

Was your test result:

Positive

Negative

Are you symptomatic?

Yes

When did your symptoms begin?

Have you been on campus since your symptoms began?

Yes

Please select all dates you have been on campus since your positive test, exposure or symptoms began

Date List

Please list all locations you visited and/or classes with section and CRN you have visited on campus since your positive test, exposure or symptoms began.

Class or Location

Added Locations

No locations have been added yet.

Please provide all close contacts with individuals on campus since your positive test, exposure or symptoms began.

First Name

Last Name

Close Contact with:

No one has been added yet.

If you are reporting that you were exposed to a person with COVID-19, did the exposure occur

On Campus

Off Campus

If the exposure occurred on campus, please list the class (section and CRN) or location where this occurred:

Class or Location

Added Locations

No locations have been added yet.

Employee COVID-19 Reporting

COVID-19 Information

Employee Form for COVID-19