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Self-Reporting Form for Employees

Any and all information gathered through Catawba College’s reporting process will remain as private as possible. See The U.S. Department of Health and Human Services for specific regulations around privacy and confidentiality and The U.S. Department of Education for specific regulations related to student privacy. The reporting requirement will allow Catawba College to provide education, guidance, and care monitoring to the individual(s) impacted and for the greater campus community.

The information submitted on this form will go to the Director of Human Resources only.

Individual Completing this Form


Report Information


Please provide information on how, where and under what circumstances you came into contact with someone who may have had COVID-19.

PLEASE PROVIDE INFORMATION REGARDING PERSON(S) BELIEVED TO BE AFFECTED BY COVID-19:

Additional Information

Dates believed to have been in contact with someone affected by COVID-19 (please provide calendar dates)

Acknowledgement


I acknowledge by submitting this form, that I will not be allowed to return to Catawba College until at least 14 calendar days after notice of contact/exposure to COVID-19. After the 14 calendar day period, I will be notified by the Director of Human Resources of my return date to work, if I am not showing symptoms of COVID-19.

By submitting this form, I am self-quarantining. I am also notifying the College that I am aware that I must receive written approval from the College prior to returning to campus.

I attest the information provided is true and correct to the best of my ability and understand that any false statements/allegations may be subject to disciplinary actions including but not limited to expulsion or termination.
* = Required Field