COVID-19
Student Self-Identification

COVID-19 Identification Form

Name(Required)
please include specific location of suspected COVID exposure

Please provide information regarding additional person(s) believed to have been in close contact with you and could be affected by COVID-19

Close contact is defined as exposure within a 6-foot radius for longer than 15 minutes.
Is this individual(s) an Iowa Valley student? (this may be Ellsworth, Marshalltown, Grinnell, or Continuing Education)

Please provide additional information

Are you currently sick or exhibiting symptoms?(Required)
(Please provide calendar dates)
Are you fully vaccinated? Have you received the 2-shot series of Pfizer/Moderna or 1-shot J&J?
Have you received a Booster shot?
Statement of Acknowledgement(Required)