The information requested below will be used to inform the College Administration of potential exposure of confirmed cases of COVID-19 at Middlesex Community College, and it may be shared with the local Department of Public Health. Your report and participation is voluntary, but it is critical to the College’s efforts to control the spread of COVID-19 at the College and within the community. Although this form requests your name and other personally identifiable information, that information may be shared only with the Department of Public Health. By providing this information to the College, I consent to its use as described above. Please email KHogan@mxcc.edu with any questions.