Coronavirus COVID-19 Exposure Form
This form should be used to report all students, faculty and staff who (1) tested positive for COVID-19, (2) were exposed to someone who tested positive for COVID-19, or (3) were instructed to stay home and self-quarantine because they are exhibiting symptoms of COVID-19.

Since this is a rapidly evolving situation the criteria indicated above may change as the NYC Health Department updates its recommendations.

The current NYC Health Department COVID-19 guidance, What You Need to Know Now About COVID-19 (PDF, April 4), is available at https://www1.nyc.gov/assets/doh/downloads/pdf/imm/coronavirus-factsheet.pdf
Name of person completing this form *
Name of the person who either (1) tested positive for COVID-19, (2) was exposed to someone who tested positive for COVID-19, or (3) was instructed to stay home and self-quarantine because they are exhibiting symptoms of COVID-19 *
EMPLID of the person indicated above *
Relationship to City Tech *
Required
Date of their positive COVID-19 test, exposure, or self-quarantine *
MM
/
DD
/
YYYY
Date when COVID-19 symptoms first appeared *
MM
/
DD
/
YYYY
If known, any dates on campus during the 14 days prior to diagnosis, including locations, and other people in close contact.
If known, any contact in the 14 days prior to diagnosis with other City Tech students, faculty, or staff, including their names.
This information will be shared with City Tech Coronavirus COVID-19 Response Team. Thank you very much for your report. We appreciate all you do to keep our community safe and to provide assistance to our students. Be well and stay safe. Together we will make it through these difficult times.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy