COVID19: Student Absence Form
Student Name
*
First Name
Last Name
Current Resident Address
*
Street Address
Street Address/Apt #
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Student Email Address
*
example@example.com
Alternate Email Address
example@example.com
Mobile Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
I am currently enrolled at SCC (Check all that apply)
*
Credit Classes
AEL/HISED Classes
CBIZ Classes
Other
If answer is "Other" above, please describe
Mode of Delivery: (Check all that apply - Types of courses you are taking)
*
Face to Face
Virtual (Online)
Both
SCC location of your classes (check all that apply)
*
West Burlington Campus
Keokuk Campus
Fort Madison Center
Mt. Pleasant Center
CBIZ Center
Online
Do you live in College-owned Student Housing?
*
Yes
No
COVID-19 Related Reason(s) for My Absence
(Please complete all that apply)
I have TESTED POSITIVE for COVID-19
Tested Positive Date
-
Month
-
Day
Year
Date
Date of Initial Symptoms
-
Month
-
Day
Year
Date
I have BEEN EXPOSED (less than 6ft distance for 15+ consecutive minutes) to someone else confirmed positive for COVID-19
Date of Most Recent Exposure
-
Month
-
Day
Year
Date
I am EXPERIENCING SYMPTOMS OF COVID-19
Date of Initial Symptoms
-
Month
-
Day
Year
Date
I have to be absent from classes for OTHER COVID-19 related reasons
Describe Reasons
Awareness and Consent
YES, I give permission to SCC to notify my instructors, other appropriate College officials, and or the County Public Health Department of the reason(s) for my absence.
No, I do not give permission to SCC to notify my instructors, other appropriate College officials, and or the County Public Health Department of the reason(s) for my absence.
Submit
Should be Empty: