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Communicable Disease Case Report
IF YOU HAVE TESTED POSITIVE FOR ANY COMMUNICABLE DISEASE AND HAVE RECENTLY ACCESSED CAMPUS, IT IS IMPORTANT THAT STUDENTS REPORT THEIR POSITIVE RESULT IMMEDIATELY TO STUDENT HEALTH SERVICES BY FILLING OUT THIS FORM. PLEASE NOTE THAT EMPLOYEE CASES ARE TO BE REPORTED DIRECTLY TO HUMAN RESOURCES AT HUMANRESOURCES@MPC.EDU.
PLEASE KNOW WE WORK COLLABORATIVELY WITH THE MONTEREY COUNTY HEALTH DEPARTMENT EPIDEMIOLOGY AND SURVEILLANCE UNIT TO ENSURE THE HEALTH AND SAFETY OF OUR CAMPUS COMMUNITY.
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Email *
First and Last Name *
Student I.D. #  *
Home Address (please include city & zip code) *
phone number *
date of birth *
MM
/
DD
/
YYYY
What is your diagnosis? *
date symptoms first began *
MM
/
DD
/
YYYY
What symptoms have you experienced?
date of diagnosis *
MM
/
DD
/
YYYY
Diagnosing Medical Provider/Clinic *
Last date and time you were on campus   *
MM
/
DD
/
YYYY
Time
:
What room number and/or building were you in?
(Ex. Student Services Building- Counseling Dept. or Life Science Building- Room 205)
 *
Do you have a child enrolled in the ECE Lab School? *
Required
Are you on an MPC Athletic Team? *
If you are on an MPC Athletic Team, when and where was the last practice or competition you were at?
Verification *
Required
What's next?
MPC Student Health Services will respond to your report within 2 business days. In the meantime, please stay home and continue to follow the precautions recommended by the Public Health Department and your healthcare provider. 
A copy of your responses will be emailed to the address you provided.
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