COVID-19 Exposure Notification Form

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

COVID-19 Exposure Notification

If you have tested positive for COVID-19 or have been exposed to someone who has tested positive DO NOT visit campus or attend in-person classes. Please complete this form and upload appropriate documentation.

Personal Information

Name*

First Name

Initial

Last Name

Student A#*

Email Address*

Cell Phone*

Choose:*

I have tested Positive for COVID-19 I have been exposed (in close contact) to someone who has tested positive.

If so, what was the date when test was taken (not when results were received)*

If so, what was the last date of contact with the person who tested positive?*

Why did you get tested?*

I was experiencing symptoms I was told to get tested I randomly decided to get tested Close contact/exposure

Other:

Are you currently experiencing symptoms?*

Yes No

Have you been fully vaccinated within the last 6 months? (This information is optional but is helpful when determining how long the isolation period)*

Yes No Waiting on second shot

Other:

Have you visited campus since your exposure or positive test?*

Yes No

Please list the places that you have visited on campus since exposure or receiving positive status (Bessemer or Birmingham) AND the people with whom you have been in close contact?*

Close Contact definition & Documentation Proof

Close contact: is defined as within 6 feet of an infected person (laboratory-confirmed) for a cumulative total of 15 minutes or more over a 24-hour period. You will find the latest guidance from the CDC at this link https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/end-home-isolation.html

In order to determine the period of your isolation or quarantine upload a picture of your positive test results.

Upload a picture of your positive test results here.

No File Chosen

File uploads may not work on some mobile devices.