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COVID-19 Data Collection WorksheetInstructions: Complete Form and submit through appropriate Dean/Director to the VP of Human Resources -Person Reporting Positive Test Results or Potential Exposure: FORMTEXT ?????Date/Time Reported: FORMTEXT ?????Name and Telephone Number of Positive or Potentially Exposed Student, Employee, or Visitor (Highlight or circle student, employee or visitor, as appropriate): FORMTEXT ?????Date of Positive Test or Potential Exposure: FORMTEXT ????? (Note: Provide answers to the following in the text boxes below) FORMTEXT ?????Has the individual experienced symptoms, been tested for the virus, or received a positive test result? If so, please describe all current and prior symptoms and when those symptoms first occurred. Ask if and when the person was tested, and the results of the test. Please advise the person to isolate themselves for 14 days and refer them to the CDC website for additional guidance and a self-checker located at . The person shall be advised not return to campus until they can provide documentation from a doctor or authorized medical provider reflecting it is safe for the person to return to campus or they have completed i an isolation of 14 days, with no lingering symptoms, including no fever (without taking fever-reducing medicines). FORMTEXT ?????Description of College campus locations visited and any off-Fayetteville campus locations visited while symptomatic. List all FTCC buildings, including room numbers, and common areas (library, breakroom, restroom, etc.) visited subsequent to known exposure and the specific dates those locations were visited. Notify maintenance and facilities for immediate cleaning of all locations operated by the College. The Vice President for Human Resources as the COVID Coordinator will ensure maintenance and cleaning have completed their cleaning of all locations in a timely manner. FORMTEXT ?????Student information collection for positive test results or all potential exposure: Attach a printed copy of the student’s class schedule or list ALL current classes, instructor(s) names, and any other available contact information. The Dean/Director in coordination with the Senior Vice President of Academic Student Services shall jointly decide if any classes will be required to transition to on-line until further notice out of an abundance of caution. Additionally, the decision of notification to all students that have tested positive or potentially exposed individuals should be determined in coordination between the Deans, COVID coordinator, and the Senior Vice President of the risk of potentially exposing others and whether the individual will need to quarantine and for how long. (Dean or Director to notify the VP for Human Resources when student notification has been completed). FORMTEXT ?????Has the person been consistently wearing and facial covering, practicing social distancing, and frequently washing hands or using hand sanitizer? Yes FORMTEXT ?????No FORMTEXT ?????If faculty, have students in their classes followed the College’s stated CDC practices on a consistent basis?Yes FORMTEXT ?????No FORMTEXT ?????The person completing this form, needs to contact the individual and collect as much contact tracing information as possible and enter relevant information on the next two pages of the C40 form. Enter Other Pertinent Information or Remarks not already provided (Including any possible cluster(s) – A cluster is defined as 5 or more cases within the same general campus location(s): FORMTEXT ?????Collect from positive or potential exposure as much of the following information as can be collected during the initial notification. List Contact Tracing Points of Contact below: A close contact is a person within 6 feet for 15 minutes or more, starting 48 hours prior to symptom onset through time of interview. List children living in household - notify parent of quarantine if under 18 yrs. Interviewer name: FORMTEXT ????? Date: FORMTEXT ????? Time: FORMTEXT ?????Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ????? Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ????? Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ????? Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ?????Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ?????Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????Additional pages of contacts: Y FORMCHECKBOX N FORMCHECKBOX List Contacts below: Continuation:6.Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ?????Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????7.Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ?????Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????8.Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ?????Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????9. Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ?????Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????10. Contact Name: FORMTEXT ????? Relation: FORMTEXT ????? Minor: Y FORMCHECKBOX N FORMCHECKBOX Age/DOB: FORMTEXT ?????Parent or Guardian Contact Name (if minor): FORMTEXT ?????Phone #s: FORMTEXT ?????Date of last exposure: FORMTEXT ????? Lives at Case Address: Y FORMCHECKBOX N FORMCHECKBOX Preferred Language Spanish FORMCHECKBOX English FORMCHECKBOX Other: FORMTEXT ?????Notes: FORMTEXT ?????Obtain local Mailing Address, County of Residence, and Email Address of the positive or potentially exposed individual and enter that information below: FORMTEXT ?????As of September 14, 2020 College Rules and Procedures – Communicable Diseases, including but not limited to COVID-19Fayetteville Technical Community College is observing strict safety rules aimed at preventing the transmission of COVID-19 for the safety of students, faculty, staff, administration and/or College visitors or vendors. The College’s safety rules and procedures expected while on College properties are as follows: Wear Face coverings: All persons on college properties are required to wear a face mask or CDC approved alternative covering except in situations where only a single person occupies an office which can be used to separate the occupant from others. When others visit the office, all occupants must immediately put on a CDC approved face covering before engaging with one another. This mandatory College procedure to wear face CDC approved face coverings is a protection for others an is applicable to all students, faculty, staff, administration, and/or other College visitors. Daily Temperature Checks: Everyone is required to have their temperature checked when initially entering a building on campus. If the temperature is normal, a color-coded arm-band will be provided which must be worn for the duration of the day. When changing buildings or other locations, with the proper color of the day armband, additional temperature checks will not be required for the remainder of the person’s visit on that particular day. Social distancing: Everyone on College properties shall keep at least 6 feet between themselves and any other person at all times. Students, faculty, staff, administrators, and visitors shall maintain social distancing while in any locations including hallways and common areas, except in the event of an emergency. Please be patient as maintaining social distancing may slow your ingress into and egress from buildings, labs, offices, and classrooms. Hand washing or sanitizing: The College has placed hand sanitizer stations in various public spots in buildings throughout campus. People are encouraged to clean their hands frequently using hand sanitizer if hand-washing is not immediately possible. Thorough hand-washing, using soap and water, for at least 20 seconds at a time, is encouraged periodically throughout the day. Stay home when you are sick, when your temperature is above 100.4 or if you suspect you have been exposed to COVID-19. Students shall notify their instructors as soon as practical, and faculty, staff, and administrators shall notify their immediate supervisor prior to their next scheduled work period.Screening Checklist for COVID-19 (Provided as information):Exposed but not experiencing symptoms: Cannot come to the College and must stay at home for 14 days since the initial date of potential exposure to the virus.Diagnosed positive and experiencing no symptoms: Cannot come to the College and must stay at home for 10 days since the first positive test result.Confirmed positive for COVID-19 or the person has not been tested and is experiencing at least one symptom (fever, chills, shortness of breath/difficulty breathing, new cough, new loss of taste or smell: Cannot come to the College for 10 days beginning with the first symptom, experiencing no fever for 24 hours (without the use of fever-reducing medicines), AND symptom(s) improvement, including coughing and shortness of breath.If negative test result and no fever for 24 hours (without the use of fever-reducing medicines) and the individual has felt well for 24 hours, the person may return at the expiration of those 24 hours.If a confirmed diagnosis other than COVID-19 (e.g. stomach virus, ear infection, etc.) the person may return to the College unless a medical authority limits such access for a duration of time.Definitions: Exposure refers to being within 6 feet of someone, for 15 minutes or longer, that has been diagnosed with COVID-19. When is it recommended to seek out a test? Current CDC and Department of Health guidelines recommends not seeking a test until 6 or more days since exposure to lessen the chances of a false negative or false positive unless and earlier test is prescribed by a medical authority.Instructions for Timely Reporting: College first-line supervisors shall complete the C-40 form, immediately upon becoming aware of a possible COVID-19 exposure, positive COVID-19 test result, or other communicable disease exposure. The completed form shall be forwarded as quickly as possible through the appropriate Director/Dean level supervisor to the Vice President of Human Resources who is designated as the College’s COVID-19 Coordinator. Also, the first-line supervisor must notify the facilities engineer of any rooms needing immediate cleaning. The person completing this form will also ensure to the degree possible complete details surrounding the potential exposure or positive test result and only when absolutely necessary provide additional information at a later time (not to exceed 4 working hours). The COVID-19 Coordinator shall maintain a confidential roster of potential exposures and positive test results (by name) based upon the information provided in the completed C-40 form. This roster will be periodically shared with the Executive Council and the President who will maintain confidentiality of the roster. Therefore, thorough completion of the form is absolutely necessary to ensure all information reported is correct, timely, and fully documented. Questions concerning completion of the fill-in form can be addressed to your appropriate Dean, Director, Associate Vice President or Vice-President/Senior Vice President. ................
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