Faculty, staff, or students who are staying home due to illness should complete this confidential health and safety intake form. A nurse from the QCC Health and Wellness Team will contact you. If you need immediate medical attention, call 911.

Name
Address
Preferred type of communication
Type (I am a...)
I have had a confirmed positive test for:
If you test positive for Covid-19, Flu or another contagious illness, please DO NOT come to campus until you have spoken with a QCC Health Consultant
Have you seen a healthcare provider or medical professional?
Have you had contact with any sick people recently?
Are any other household members affected?
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