Illness Intake Form | Quinsigamond

Faculty, staff, or students who are staying home due to illness should complete this confidential health and safety intake form. A nurse from the QCC Health and Wellness Team will contact you. If you need immediate medical attention, call 911.

First

Last

Pronoun

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone

Preferred type of communication

Call

Text

Type (I am a...)

Faculty Member

Staff Member

Student

PreSchooler

Frequency on Campus

Most recent visit to campus

I have had a confirmed positive test for:

COVID-19

Strep

Flu

Other…

If you test positive for COVID-19 by either rapid or PCR test, please DO NOT come to campus until you have spoken with a QCC Health Consultant.

Have you seen a healthcare provider or medical professional?

Yes

Have you had contact with a person experiencing COVID-19 symptoms?

Yes

if yes, date of contact

Are any other household members affected?

Yes

Date Your Symptoms Started

Please briefly describe your situation (including symptoms)

Have you been vaccinated for COVID-19?

Yes

Parent/Guardian Name

First

Last

Parent/Guardian Phone Number

Classroom

Days preschooler attends each week

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