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FSCJ COVID-19 CASE MANAGEMENT
Thank you for notifying us about your recent positive test results for COVID-19. Please know that we are here to support you during this time and hope that you have a quick recovery. As part of our contact tracing process, please respond to the below questions as quickly as possible. This is your only contact needed at this time. If you are a student FSCJ will contact your instructor and any students you may have come into contact with at FSCJ. All information is held in strict confidence according to FERPA.
Have you previously submitted this form with us before?
Required
*
Have you previously submitted this form with us before?
Yes
Have you previously submitted this form with us before?
no
Please reach out to us at AccommodateMe@fscj.edu prior to submitting this form.
FSCJ Relation
Required
*
Please indicate your status at the college.
FSCJ Relation
Student
FSCJ Relation
Staff
FSCJ Relation
Faculty (Full Time or Adjunct)
FSCJ Relation
Vendor
First Name
Required
*
Last Name
Required
*
Middle Name
User ID
Required
*
Name of your business:
Required
*
Relationship
Required
*
Self, Spouse, Daughter, Supervisor, Parent, etc.
Phone Number
Required
*
xxx-xxx-xxxx
Email Address
Required
*
Use an email address that you check regularly.
Preferred method of contact:
Required
*
Phone
Email
Name of immediate supervisor:
Are you able to work remotely?
Are you able to work remotely?
Yes
Are you able to work remotely?
no
Have you received positive test results for COVID-19?
Required
*
Have you received positive test results for COVID-19?
Yes
Have you received positive test results for COVID-19?
no
Were you in close contact with someone who has tested positive?
Were you in close contact with someone who has tested positive?
Yes
Were you in close contact with someone who has tested positive?
no
Date Tested
January
February
March
April
May
June
July
August
September
October
November
December
01
02
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30
31
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Date of Results
January
February
March
April
May
June
July
August
September
October
November
December
01
02
03
04
05
06
07
08
09
10
11
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30
31
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Have you experienced any symptoms?
Required
*
Have you experienced any symptoms?
Yes
Have you experienced any symptoms?
no
Please select all of your symptoms that apply:
Required
*
Please type any symptoms you listed under other:
Date of Symptoms
January
February
March
April
May
June
July
August
September
October
November
December
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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25
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27
28
29
30
31
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Start of Isolation
January
February
March
April
May
June
July
August
September
October
November
December
01
02
03
04
05
06
07
08
09
10
11
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14
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31
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Class(es) you are taking at FSCJ
Also include the name of your instructor(s) so they can be contacted. Please type NA if you are not taking any courses this semester.
Are any of your classes on campus?
Required
*
These can be labs, clinicals, or other meetings with instructors and students.
Are any of your classes on campus?
Yes
Are any of your classes on campus?
no
Which campus/center?
Deerwood, Downtown, Kent, Nassau, North, South, Cecil, etc.
When were you last on campus?
Required
*
January
February
March
April
May
June
July
August
September
October
November
December
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Please list areas visited while on campus? Locations: building, classrooms, & offices.
Required
*
Try to be as specific as possible about areas in addition to your classes where you might have visited.
Which campus(es) did you visit?
Required
*
Select all that apply.
+
Select visible
-
Clear visible
clear filtering
Downtown Campus
North Campus
South Campus
Kent Campus
Nassau Center
Cecil Center
Deerwood Center
AO
URC
ATC
Other
11 of 11 visible
0
of
11
selected
show selected
show all
Were you in contact with anyone at FSCJ up to 48 hours prior to onset of symptoms?
Were you in contact with anyone at FSCJ up to 48 hours prior to onset of symptoms?
Yes
Were you in contact with anyone at FSCJ up to 48 hours prior to onset of symptoms?
no
Are you aware of their names? If so, please list them.
Try to include as much information as possible about people you may have had contact with in addition to teacher(s) and students in your classe(s).
Were you wearing a Mask/Personal Protective Equipment (PPE) during your interaction?
Were you wearing a Mask/Personal Protective Equipment (PPE) during your interaction?
Yes
Were you wearing a Mask/Personal Protective Equipment (PPE) during your interaction?
no
Do you need Additional Support from FSCJ?
Required
*
Do you need Additional Support from FSCJ?
Yes
Do you need Additional Support from FSCJ?
no
How does your condition affect major life activities?
Required
*
For example, breathing, concentration, sitting, sleeping, working, etc.
Please describe how the condition affects your ability to perform the essential functions of your job or success as a student:
What accommodations are you requesting?
Accessibility Accommodation
Accommodation Type
Required
*
Upload supporting document(s)
Please prove you are not a robot
Document Information
Document Title
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*
File
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*
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