COVID-Questionnaire – Adult Ed

Name(Required)

First Last

Personal Email(Required)

Adult Ed Site(Required)

Last date you attended(Required)

Have you tested positive for COVID?(Required)

No - not exposed, just feel sick

No - was exposed to someone who tested positive

Yes

Phone(Required)

Date of Birth(Required)

Date you tested positive for COVID(Required)

Do you have COVID symptoms?(Required)

Yes

Date your COVID symptoms started:(Required)

On what date were you last exposed to someone with COVID-19??(Required)

Were you wearing a mask and social distancing?(Required)

Yes

Does the person that tested positive for COVID live in your home?

Yes

When did that person test positive for COVID?

If the potential exposure is from being around a family member, friend, co-worker, associate, etc., what is the level of contact?

Close Contacts

Names and County of residence (if known) of anyone who had close contact on campus (not wearing a mask or social distancing) with you AFTER onset of symptoms:

Comments

COVID-Questionnaire – Adult Ed

About Lanier Tech

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About Lanier Tech

Resources

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