Chemeketa COVID-19 Illness/Exposure Questions
Completion of this form will expedite and facilitate Chemeketa's COVID-19 assessment, notification and contact tracing efforts.  

If you have been directed to complete this form by an instructor or supervisor please fill out the answers as they apply to YOU.

NOTE:  If completing this form for someone else, please answer the questions as they would if they were filling out the form.

NOTE:  If you have had a known exposure or tested positive, be prepared to isolate or quarantine for a minimum of 5 days.  DO NOT RETURN to campus until notified by the college.  If you are not contacted within 48-hours, please send an email to COVID19@chemeketa.edu.
Sign in to Google to save your progress. Learn more
Email *
YOUR Full Name *
Student or employee:  enter YOUR Full name (first and last name) if you have been directed to complete this form by instructor or supervisor.  Supervisor or instructor:  enter the name of the sick or exposed person if you are completing the form on their behalf.
Status *
Status of the person sick with or exposed to COVID-19.  Enter YOUR status if directed to complete this form due to a possible exposure.
K-Number
YOUR K-Number or K-Number of the Sick or Exposed Individual if directed to complete form for someone else.
Vaccinated? *
Are YOU fully vaccinated?  Has it been 2 weeks after your second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine?
Vaccine date?
Date YOU received last vaccine in your initial series?
MM
/
DD
/
YYYY
Booster shot?
Have YOU received a vaccine booster shot?
Clear selection
Booster date?
Date you received vaccine booster shot?
MM
/
DD
/
YYYY
Supervisor/Instructor *
Please enter name of instructor or supervisor of ill, suspected ill or COVID-positive student/staff.  If you are a student, this should be the name of your instructor.  If an employee, this should be the name of your supervisor.
Campus/Center? *
Last campus/center visited
Required
Areas Visited *
Please list areas, buildings and/or rooms visited.  (e.g. Bldg 2, room 217 or B5/101)
Date Last at Campus/Center? *
MM
/
DD
/
YYYY
Duration of Visit *
Please enter the total length of YOUR visit to campus or center.  Example:  15-minutes or 2-hours
Symptoms (if Any) *
Select all of the symptoms experienced that YOU are experiencing.  Use the "Explain Nature of Exposure" section at the end of this form to report symptoms for others (if necessary).
Required
Symptom(s)/Exposure Start Date *
Enter date YOUR symptoms began if you are sick.  Enter YOUR first close contact exposure to a COVID-19 positive or presumed positive person if you have no symptoms.
MM
/
DD
/
YYYY
COVID-19 Test? *
Have YOU been tested for COVID-19?  
Test Results?
YOUR test results for COVID-19.
Clear selection
COVID-19 Test Date?
MM
/
DD
/
YYYY
Any Cleaning Protocol Used?
Was there any cleaning, sanitizing or disinfecting of the area where the exposure may have occurred?
Clear selection
Others in Close Contact? *
Close contact is defined as "someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 to 14 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated."
Close Contact Names? *
Please list the names of students or staff within close contact of YOU during the two (2) days before you came down with COVID-like symptoms.  This information will be required by the local county public health authority for notification and contact tracing purposes.  If NO close contact, type in N/A.
Explain Nature of Exposure? *
Please provide brief narrative of exposure (i.e. who, what, where, when and how long, were masks worn by student/staff and suspected sick person?)  Please indicate if you've had NO exposure and are only completing form due to COVID-19 symptoms (e.g. No exposure, completing form because of symptoms.)
Phone Number *
NOTE:  Phone number will only be used if we need follow up for more information for contact tracing purposes.
NOTE:  If you have had a known exposure or tested positive, be prepared to isolate or quarantine for a minimum of 5 days.  DO NOT RETURN to campus until notified by the college.  If you are not contacted within 48-hours, please send an email to COVID19@chemeketa.edu.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Chemeketa Community College. Report Abuse
Google Forms