COVID-19 Self Report

To ensure that Lake Michigan College can provide support and resources to students who have been exposed to or tested positive for COVID-19, the college is requesting that individuals 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.

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

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 proved the approximate date you were exposed to a confirmed 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.

Are you currently self-isolating?

Yes

No

Questions, comments or other information

Thank you for assisting in keeping our campus healthy. Until directed by our Director of Advising or Vice President of Student Affairs you may not return to campus. The Director of Advising will work with you and your instructors to ensure that your coursework is not impacted and that you are able to continue making progress in your classes, as you feel able while you’re away from campus.

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