COVID-19 Self-Reporting Form for Faculty and Staff

To ensure that Spartanburg Methodist College can provide support and resources to faculty and staff who have been exposed to or tested positive for COVID-91, the College requests that individuals complete this form. This information will assist the College with responding to occurrences on the SMC campus.

Spartanburg Methodist College is committed to maintaining your privacy. The information you provide will be used to provide support and resources only.

Your Name Your Name * First Last
Your Phone Number Your Phone Number * - ### - ### ####
Your Supervisor's Name *
Your Email address
(to be used for confirmation of form submission) *
Have you notified your supervisor? *

Have you notified your supervisor? Yes No
Reasons for submitting this self-report *

Reasons for submitting this self-report I have been exposed to a confirmed or probable case of COVID-19 I am caring for someone with COVID-19 I am experiencing COVID-19 symptoms I have been diagnosed / tested positive for COVID-19 I have traveled outside of the United States or been on a cruise in the last 14 days A member of my household tested positive for COVID Other Other
Date you were exposed to a confirmed or probable case of COVID-19 Date you were exposed to a confirmed or probable case of COVID-19 * / MM / DD YYYY
Date you started caring for someone with COVID-19 Date you started caring for someone with COVID-19 * / MM / DD YYYY
Date you started experiencing COVID-19 symptoms Date you started experiencing COVID-19 symptoms * / MM / DD YYYY
Date you were tested positive for COVID-19 Date you were tested positive for COVID-19 * / MM / DD YYYY
The test on this date is a re-test for a previous positive test. *

The test on this date is a re-test for a previous positive test. Yes No
Date you returned from traveling outside of the United States or went on a cruise Date you returned from traveling outside of the United States or went on a cruise * / MM / DD YYYY
Date a member of my household tested positive for COVID. Date a member of my household tested positive for COVID. / MM / DD YYYY
Date for Other Date for Other * / MM / DD YYYY
Please provide information about your close contacts below. Close contact is defined as someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.

If you test positive for COVID-19, with or without symptoms: Please provide the first and last names of any SMC employees or students with whom you have had close contact from two days before when you noticed symptoms until you began isolation or (if no symptoms) two days before you were tested until the time you began isolation.

If you have been exposed to someone with COVID-19, confirmed or suspected: Please provide the first and last names of any SMC employees or students with whom you have had close contact from the date of your most recent exposure until the time you began quarantine.

If you have not been in close contact with any SMC employees or students in the time frame noted above, enter None. *
Are you currently self-isolating? *

Are you currently self-isolating? Yes No
When did you begin self-isolating? When did you begin self-isolating? * / MM / DD YYYY
To read the CDC Guidelines for Quarantine/Isolation, click here

To read the CDC Guidelines for When You Can End Isolation, click here

I acknowledge that I understand CDC guidance for self-isolation/self-quarantine and return to work. *

To read the CDC Guidelines for Quarantine/Isolation, click here

To read the CDC Guidelines for When You Can End Isolation, click here

I acknowledge that I understand CDC guidance for self-isolation/self-quarantine and return to work. I agree
By submitting this form, I acknowledge that I understand I am signing this document and the information given is accurate. *

By submitting this form, I acknowledge that I understand I am signing this document and the information given is accurate. I agree
For the next steps you will need to take, click here.
I acknowledge that I have read the next steps to take. *

I acknowledge that I have read the next steps to take. I agree
Date Date / MM / DD YYYY

COVID-19 Self-Reporting Form for Faculty and Staff

COVID-19 Self-Reporting Form for Faculty and Staff

For the next steps you will need to take, click here.