COVID-19 Questionnaire

First and Last Name of Individual with Potential or Confirmed Exposure to COVID-19*

Student ID or Employee ID#

Phone*

Email*

Affiliation*

Student
Employee
Other

Date of Positive Test

Is the individual exhibiting any COVID-like symptoms?*

Yes
No

Some examples may include: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat Congestion or runny nose Nausea or vomiting Diarrhea

Date of Symptom On-Set

When were you last on campus or at an education center?

When were you last in close proximity to a Palomar College Student or employee?*

List the offices and/or classrooms in which you were physically present on campus or at an education center during the 48 hours prior to your positive COVID test (or symptom onset, whichever came first)

Are you completing this form on behalf of someone else?*

Yes
No

Name of Individual Completing Form*

Email of Individual Completing Form*

Hidden

Please Describe the Exposure and Symptoms

Hidden

Has the Exposure Been Confirmed by a Health Official or Health Care Provider?

Yes
No
Unknown

Hidden

Did the Exposure Occur in the Course of Authorized Work or Class Activities?

Yes
No
Unknown

Hidden

Location

Campus, Building and/or room number

Hidden

Class Number or Name

Class Number (i.e. 55012) or description if you don't know the class number.

Hidden

Were you in:

A classroom
An assigned workspace

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What is the specific location?

Hidden

Is the Individual with Potential or Confirmed Exposure Presently Self-Isolating?

Yes
No

Coronavirus (COVID-19) Updates

Coronavirus (COVID-19) Updates

Contact Information

Public Information Office

Hours of Operation

Communications Library

All Updates