COVID-19 Contact Tracing Questionnaire for DigiPen Staff/Faculty (Exposure)

This contact tracing questionnaire is used by Student Affairs Department and/or HR to prevent the spread of infectious disease. In general, contact tracing involves identifying people who have an infectious disease, or possibility of having such disease (cases) and their contacts (people who may have been exposed) and working with them to interrupt disease transmission. Please answer the following questions in order to protect our community.

Your Name Your Name * First Last
Your Email Address *
Your Phone Your Phone * - ### - ### ####
You are: *

You are: DigiPen Staff DigiPen Faculty Other Other
1. Why do you believe you are “at risk” for Covid 19? *
2a. Have you been tested? *

2a. Have you been tested? Yes No Other Other
2b. If tested, when were you tested? 2b. If tested, when were you tested? / MM / DD YYYY
3. Do you need Covid 19 testing resources? *

3. Do you need Covid 19 testing resources? Yes No Other Other
4. What is your current location? 4. What is your current location? *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
5. When were you last present on the DigiPen campus? 5. When were you last present on the DigiPen campus? * / MM / DD YYYY
6. Where did you go while on DigiPen’s campus?
• What rooms were you in?
• Where in the rooms did you sit? *
7. Did you come in contact with any members of the DigiPen Community while on campus and who? How long were you in contact with these people? *
8. Are you a resident of DigiPen Housing? If so, who are your roommates? If not, do you live with other DigiPen students or community members? If so, who?
9. What are your symptoms? If no symptoms, write "no symptoms." *
10. When did you start feeling sick (if applicable)? 10. When did you start feeling sick (if applicable)? / MM / DD YYYY
11. Do you have health insurance? *

11. Do you have health insurance? Yes No Other Other
12. Have you informed your emergency contacts? *

12. Have you informed your emergency contacts? Yes No Other Other
13. Have you informed your instructors or Student Success Advisor?

13. Have you informed your instructors or Student Success Advisor? Yes No Other Other
14. Do you need help informing your instructors and Student Success Advisor?

14. Do you need help informing your instructors and Student Success Advisor? Yes No Other Other
15. What questions do you have for us?
• We will be in contact with you periodically to ensure you are recovering and to see if we can provide support and resources.
(For admin only) Follow up information (positive vs. negative results, etc.)