Coronavirus Self-Reporting Form

This self-reporting form is to notify the Division of Culture, Planning & Policy at Nevada State College of persons of persons who have tested positive or are presumed positive for Coronavirus (COVID-19), including yourself. Information reported in this form will be used by a designated NSC administrator to monitor trends.

Individuals who self-report should immediately follow these next steps:

Complete the CDC Isolation and Exposure Calculator: https://www.cdc.gov/coronavirus/2019-ncov/your-health/isolation.html.
Report your positive case through Nevada Health Response.
Follow instructions from your healthcare provider, the Southern Nevada Health District and the CDC regarding self-isolation. Note that violating SNHD orders to self-isolate or self-quarantine is punishable by state law.

Nevada State College will take every effort to protect personally identifiable information shared in this document and will not disclose your identity or the identity of anyone with a coronavirus diagnosis unless disclosure to safety and first aid personnel is required for emergency treatment or is otherwise required by law.

Self-Assessment Tool

Unsure if you should quarantine? Use this self-assessment tool to determine if you should.

TAKE SELF-ASSESSMENT

First Name*
Last Name*
Your email*
Your phone*
Your affiliation with NSC*
Please explain*
Are you a student worker?*
- Yes
- No
Department*
Your school affiliation*
Nature of this report*
Please explain*
Test status*
Date of test*
MM slash DD slash YYYY
Test results*
- Positive
- Negative
Name of person believed to be exposed to COVID-19 (including self)
Person's affiliation with NSC*
Please explain*
Person’s email address (if known)
Person’s phone number (if known)
Last date on Nevada State College campus*
MM slash DD slash YYYY
Last date you participated in an in-person NSC related activity*
MM slash DD slash YYYY
What date did symptoms begin?
MM slash DD slash YYYY
Were you in a physical space on campus within 24 hours of developing symptoms or testing positive?
- Yes
- No
Please list the spaces and classrooms you were in:
Did you spend time with other NSC Scorpions within 48 hours of developing symptoms or testing positive?
- Yes
- No
Please list the people who were your close contacts. (Close contacts are people you were closer than 6 feet to for more than 15 minutes within a 24 hour period, even if you were wearing masks, and even if it was 5 minutes at a time totaling 15 minutes.)
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.*
I acknowledge

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Self-Assessment Tool