COVID-19 Self Report

To help Lake Michigan College ensure safety on campus and provide support and resources to students, faculty and staff who are sick, have been exposed to COVID-19, or tested positive for COVID-19, please complete the self-reporting form below. This information will assist the college and public health officials with monitoring the incidence of cases occurring in our community.

Can I come to campus after I submit a self-report?

Exposed to virus

Sick

Confirmed case

Vaccinated

Unvaccinated

Vaccinated or Unvaccinated

Can return
to campus

Do not come to campus

Exposed to virus

Vaccinated

Can return to campus

Exposed to virus

Unvaccinated

Do not come to campus

Sick

Do not come to campus

Confirmed case

Do not come to campus

Please Note: The college is committed to ensuring that your submission remains private and only will be used as a means to follow LMC safety protocols and provide support and resources.

An employee completing this form is still required to report to their supervisor as well to help ensure staffing coverage and necessary cleaning protocols.

Select one

Select any that apply.

Student worker

Student athlete

Beckwith Hall resident

First Name

Last Name

LMC Department

Supervisor Name

Supervisor Email

How would you like us to contact you?

Phone Number

Email Address

	What issue are you reporting?
	I have a confirmed case of COVID-19
	I have been tested for COVID-19, but I am waiting for results
	I am exhibiting symptoms of COVID-19, but have not been tested yet
	I have been exposed to someone with a confirmed COVID-19 case
	I have been exposed to someone who is waiting for COVID-19 test results
	Other

Describe the situation you would like to report.

Please provide the approximate date you were exposed to a confirmed or suspected COVID-19 case or when you developed symptoms.

Have you been on campus OR have you physically interacted with any students, staff or faculty at any point from the time you were exposed, or two days prior to developing symptoms and/or being tested for COVID-19?

Yes

No

Please indicate the last date you were on an LMC campus.

If on campus or participating in a College-related event within previous two days of developing symptoms or being tested for COVID-19 where did you spend more than 15 minutes on campus or where did the event take place (room numbers, department areas, common areas such as lobbies, restrooms, breakrooms):

Are you currently self-isolating or quarantining?

Yes

No

If exposed to someone with a confirmed COVID-19 case, or someone waiting for COVID-19 test results, is that person a member of your household?

Yes

No

If you have had an exposure to a household member with COVID-19 or presumed to have COVID-19, are you able to socially distance from this individual?

Yes

No

List any individuals with whom you had close contact either on campus or at any work-related function within 48 hours of your first symptoms, or if you are asymptomatic, within 48 hours of the date your positive test was administered:

“Close contact” means being within 6 feet from an infected individual for a cumulative total of 15 minutes or more over a 24-hour period, with or without masks, regardless of vaccination status (unless working in healthcare facility following PPE and other safety procedures).

Questions, comments or other information

Contact Us