Request to Return to Work or Class Following COVID-19

Name*

First Last

Email*

Phone*

Choose which applies to you:*

Has it been at least 5 calendar days since the onset of your symptoms or since you began self-quarantine?*

Has it been at least 5 calendar days since your last exposure to someone positive for COVID-19?*

Are you currently experiencing any of the following symptoms? Check all that apply:*

Have you experienced any of the following symptoms during your quarantine period? Check all that apply:*

Please provide any additional details related to your current situation.

Has someone in your residence (household, dorm room, or apartment) been diagnosed with or suspected to have COVID-19?*

Are you a student or employee at Milligan?*

Employee Information

Job Title

Supervisor First and Last Name