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Southern Crescent Technical College➤Coronavirus Information➤COVID-19 Impact Form

COVID-19 Impact Form

Only submit this impact form if you have tested positive for COVID-19 or are directly impacted by COVID-19 in such a way that it hinders your ability to attend class or complete your coursework (students), or fulfill your work related dutes (employees).

This form is not associated with any financial relief.

I,
Name*
First Last
,certify that I have been directly impacted by COVID-19 and will be following medical guidelines from the center for Disease Control and Prevention (CDC), the Georgia Department of Public Health (DPH), and/or my medical provider. My voluntary submission of this form will notify the College's Pandemic Control Coordinator by email. I understand college officials may contact me for additional information.
I understand that before returning to SCTC campus/center, I must complete the COVID-19 Return to SCTC Certification Form to certify that I have followed the recommended medical guidelines referenced above.
Electronic Signature*

Enter Your Name to Sign Electronically
Testing and Exposure Information
Impact Type*
- Positive COVID-19 Test
- Direct Exposure to an Individual with COVID-19
Date of positive test*
Month
Day
Year
Date of direct contact\exposure*
Month
Day
Year
Please email a copy of your positive COVID-19 test results to covid@sctech.edu
Symptomatic*
- I am asymptomatic (Not showing\experiencing symptoms)
- I am symptomatic (Showing\experiencing symptoms)
Which campuses have you been on recently*
- Griffin Campus
- Flint River Campus
- Butts County Center
- Henry County Center
- Jasper County Center
- Other
Last date on the Griffin Campus*
Month
Day
Year
Last date on the Flint River Campus*
Month
Day
Year
Last date at the Butts County Center*
Month
Day
Year
Last date at the Henry County Center*
Month
Day
Year
Last date at the Jasper County Center*
Month
Day
Year
Other Campus\College Location and Date*
If listing more than one college location and last date at that location, please list one location and date per line.
Contact Information
Student or Employee*
- Student
- Employee
Student ID #*
Phone Number*
Email*

If you have any questions or concerns, email us at covid@sctech.edu

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