Faculty & Staff Self-Reporting Portal - Alcorn State University

Alcorn State University is dedicated to protecting the well-being of its students, faculty, staff, and campus community. The University requires all students, faculty and staff to inform Alcorn officials about any recent travel, possible COVID-19 related exposures, and/or associated illness through the self-reporting form. Employees will be will be required to self-monitor their own health daily and contact Alcorn State Health Services/or their medical provider if they are symptomatic and/or exposed to COVID-19. Your information will be submitted to the Office of Human Resources and will remain confidential.

Please use the self-reporting forms to provide details regarding your recent travel, possible COVID-19 related exposures, and/or associated illness. Thank You!

First Name *

ID Number *

Email Address *

Phone Number *

Academic School/Department *

Last Name *

Office Number *

List All Buildings Occupied *

Contact with COVID-19

Have you had recent contact with someone who has been diagnosed with COVID-19? *

Yes

Please describe your last contact visit with this person.

Have you had recent contact with someone suspected of having COVID-19? *

Yes

Please describe your last contact visit with this person.

Are you having flu-like symptoms including fever, cough, or shortness of breath? *

Yes

If yes, when did your symptoms start?

Have you been tested for COVID-19?

Yes

If yes, what are your test results or when are your test results expected?

Have you received a COVID-19 vaccine? *

Yes

Which vaccine have you taken?

When did you receive your first dose?(mm/dd/yyyy)

When did you receive your second dose?(mm/dd/yyyy)

Are you feeling sick? *

Yes

If yes, describe all your symptoms.

Have you received a COVID-19 vaccine booster? *

Yes

Which vaccine booster have you taken?

When did you receive your booster dose? (mm/dd/yyyy)

Have you received a second COVID-19 vaccine booster? *

Yes

Which vaccine booster have you taken the second time? *

When did you receive your second booster dose?(mm/dd/yyyy) *

Have you received a 3rd COVID-19 vaccine booster? *

Yes

Which vaccine booster have you taken the third time?

When did you receive your third booster dose?(mm/dd/yyyy) *

Do you live on campus (on-campus housing)? *

Yes

Have you recently traveled in the last two weeks? *

Yes

Start Date of Travel:(mm/dd/yyyy) *

End Date of Travel:(mm/dd/yyyy) *

Please list cities, states, countries.

Have any other Alcorn employee traveled with you? *

Yes

If yes, please list their name(s). *

Please give any additional information you feel is pertinent. *

Please send a confirmation email to the address below*:

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