For the most up-to-date information about Coronavirus, visit the CDC website.COVID-19 TEST RESULT REPORTINGThe 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.Full Name*I am a:*StudentEmployeemyCommnet ID*Email address*Phone Number*Have you been tested for COVID-19?*YesNoWhere was the test performed?*What date was the test performed?*What date did you receive the test results?*Was the test result positive?*YesNoDo/Did you have symptoms?YesNoWhat date did you begin to experience symptoms?Have you been on the Middletown Campus?YesNoWhat date(s) were you on the Middletown campus?Which building(s) and rooms(s) were you in?Have you been on the Meriden Campus?YesNoWhat date(s) were you on the Meriden campus?Which building(s) and rooms(s) were you in?Were you in close contact (within 6 feet or closer, for more than 15 minutes) with anyone at MxCC during this time?YesNoSendThis field should be left blank