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COVID-19 Report Form
Reporting Party
(all yellow fields are required)
Your Full Name
Affected Person
MCC ID
First Name
Last Name
Type
Select One
Student
Employee
Location
Select One
Kingman
Bullhead City
Lake Havasu City
North Mohave
DAC
Has the affected person been fully vaccinated?
Select One
Yes
No
Has the affected person been on campus?
Select One
Yes
No
If so, where?
Date on campus (if on campus)
Date of exposure
Date of start of symptoms
Symptoms
Date of most recent test and results, if known
Notes
Submit Form
