COVID-19 Self-Reporting Form

COVID-19 Self-Reporting Form

This form should be completed if you are an ASM teen or instructor who has been diagnosed with COVID-19 based on your symptoms or tested positive for COVID-19. If you have any COVID-19 symptoms or have tested positive for COVID-19, you should also notify your primary health care provider and work with them to determine when you can safely return to programs. Your submission of this form will allow ASM to take steps to further the health and well-being of the ASM community.

This will:

• Enable ASM to provide you with additional assistance and resources;

• Allow ASM to assess whether areas you visited will require additional cleaning.

How we will use the information you provided:

• ASM will periodically provide de-identified aggregate data to the public. Your identity will not be disclosed.

• Your instructor will be asked to work with you and provide flexibility in your program.

• We will provide limited information to ASM employees to clean spaces as appropriate. Your identity will not be disclosed to these individuals.

If you are a teen who meets the conditions above, please do not come on site. You will receive additional information and automated response once this form is submitted.

COVID-19 Information

Your full name:

Your email address:

Nature of your exposure*

Select or enter value

Affiliation with ASM*

Select or enter value

Diagnosed/Tested Positive On:*

Your Program Name:

Your Program Instructor

Your Program Location

Teen/Instructor Information

Full Name

Date of Birth

Phone Number

Email Address

Current Street Address

Questions

Where were you tested/diagnosed for COVID-19?*

If you have not been tested but have been diagnosed with COVID-19 based on my symptoms, write that in.

What date did you develop symptoms of COVID-19?

What was the last day that you were in your ASM program?*

What ASM building/facility have you been in and what was the last day that you were in the facility? Please include what rooms you have been in.*

What in-person program have you been in (within 48 hours of your positive test and/or date of first onset of symptoms)?

Where do you plan to stay while you are self-isolating?

Is there any additional support or resources we can provide to you at this time?

An ASM Staff member will need to reach out to you. What method of contact would you prefer?*

Select

Submission

Send me a copy of my responses

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