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

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 (cases) and their contacts (people who may have been exposed) and working with them to interrupt disease transmission. For COVID-19, this includes asking cases to isolate and contacts to quarantine at home voluntarily. 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. When did you test positive for Covid 19? 1. When did you test positive for Covid 19? * / MM / DD YYYY
2. What is your current location? 2. What is your current location? *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
3. When were you last present on the DigiPen campus? 3. When were you last present on the DigiPen campus? * / MM / DD YYYY
4. Where did you go while on DigiPen’s campus?
• What rooms were you in?
• Where in the rooms did you sit? *
5. 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? *
6. 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?
7. What are your symptoms? If no symptoms, write "no symptoms." *
8. When did you start feeling sick? (Please answer if applicable.) 8. When did you start feeling sick? (Please answer if applicable.) / MM / DD YYYY
9. Do you have health insurance? *

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

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

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

12. Do you need help informing your instructors and Student Success Advisor? Yes No Other Other
17. 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.