COVID-19 self reporting

Thank you for reporting to the SSC Response Team. After reporting, please remain at home until a team member contacts you to discuss your information, which may take up to 24 hours. A team member may respond by Stark State email or phone. Please make sure to check your Stark State email and provide a good phone number to reach you.

Reporting type *

Stark State role *

First name *

Last name *

Student/employee ID# *

Phone *

Stark State email *

Are you fully vaccinated? *

Yes

Per the CDC, you are not fully vaccinated until 2 weeks after the second dose of a 2-dose vaccine or 2 weeks after a single-dose vaccine.

If you are vaccinated, have you received a booster shot?

Yes

If you have received a booster shot, which brand was your booster shot?

Pfizer

Moderna

Johnson & Johnson

If you have received a booster shot, what was the date of your shot?

Have you been contacted by your local health department? *

Yes

County you live in *

What was the last date you were on campus? *

Were you in close contact (less than 6 feet for 15 minutes or more in a 24-hour period) with anyone on campus during the last two days you were on campus? *

Yes

If you answered yes to the previous question, list any close contact(s) and a contact number(s), if known?

Do you have any additional information you would like to report?

reCAPTCHA is required.

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