COVID-19 Incident Report

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* 1. I am a

Staff

Faculty

Student

Member of the Public

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* 2. Type of Incident

Confirmed COVID-19 Test

Confirmed COVID-19 Exposure

Improper Mask Usage

Individual Exhibiting Symptoms of COVID-19 (fever, cough, fatigue, loss of taste or smell, sore throat, nasal congestion, headache)

Other (please specify)

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* 3. Date and Time of Incident

Date / Time

Date

Time

AM/PM

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* 4. Location of Incident / Exposed areas (please be specific)

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* 5. Individuals Involved (if known)

If confirmed Positive COVID-19 Test

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* 6. Date of Test

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* 7. Type of Test (Rapid or PCR)

Rapid

PCR

Both

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* 8. List of potential close contacts (individuals that you were in close contact with for greater than 15 minutes, less than 6 feet apart)

YOUR CONTACT INFORMATION
-Can I remain completely anonymous? Yes. Ilisagvik College employees may not remain anonymous
-Can I give Ilisagvik my information but still keep the individual involved from finding out who I am? Yes. This allows us to contact you if we need more information. You have that choice below.
-Will you be able to address the incident if you cannot tell the individual(s) who I am? We will investigate the issue and meet with the individual. In most cases, however, we may not be able to address an anonymous report.

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* 9. Your Name

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* 10. Your Email

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* 11. I agree to allow Ilisagvik to disclose my name to the student(s) involved. [Note: the College's ability to respond may be limited if you select 'No']

Yes