1. Have you tested positive for COVID-19?

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Yes

No

2. If yes, what date was your COVID-19 test administered?

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Enter Date:

Not Applicable

3. Have you physically been on the City Tech campus during the past 10 days?

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Yes

No

4. If yes, what date(s) were you on campus?

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Enter Date:

^{(e.g. 01/01/22, 01/02/22, 01/03/22)}

Not Applicable

5. Indicate the location(s) you visited while on campus. (Include the building and room number for each location.)

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Enter Location:

Not Applicable

6. On this date(s), were you in close contact with anyone while you were on campus?

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As per the NYC Health Department in NYC, close contacts are people who have been within 6 feet of someone who has COVID-19, for 15 minutes or more over a 24-hour period. This can be from two days before the person with COVID-19’s symptoms began (or if they have no symptoms, two days before they tested positive). Usually, everyone living with someone who has COVID-19 are close contacts.

Yes

No

7. If yes, indicate who you were in close contact with while on campus and how the close contact occurred.

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Enter Contact and Encounter:

Not Applicable