Quarantine Certification Form

CERTIFICATION OF ILLNESS or QUARANTINE

Name*
First Last
I (Your Name Above), a student/employee of New River Community and Technical College, do, by my signature below, certify that:
Email*
I am a*
- New River CTC student
- New River CTC employee
Please provide the name of the New River CTC employee who directed you to this form:
I have:*
- have tested positive for COVID-19
- been ill, or experiencing cold/flu-like symptoms
- been directly exposed to a known coronavirus case
- a need for dependent/child care due to K-12 closures
Illness Start Date
MM slash DD slash YYYY
Illness End Date
MM slash DD slash YYYY
I have had the following symptoms:
I decided to self-quarantine due to this condition, from
Self-Quarantine Start Date
MM slash DD slash YYYY
Self-Quarantine End Date
MM slash DD slash YYYY
New River Community and Technical College is following the guidance of the Centers for Disease Control regarding steps to diminish the spread of COVID-19/coronavirus. Visit https://www.cdc.gov/coronavirus/2019-ncov/your-health/quarantine-isolation.html for information on the CDC's guidelines on quarantine and isolation. If you are ill, stay home and contact your supervisor regarding your absence and the submission of sick leave in KRONOS. The CDC has urged colleges and universities to modify, where possible, policies that make it difficult to follow the recommendation of self-isolation. In support of that guidance, New River Community and Technical College has adopted a CERTIFICATION OF ILLNESS or QUARANTINE form which students/employees can use during this period in lieu of medical documentation when absent due to illness. This form can also be used if you need to self-quarantine for a specific coronavirus risk. If concerning an employee, and the nature of an employee’s work lends itself to working remotely, they may discuss that with their supervisor, who may ask the area Vice President to approve or deny that request. Faculty would be expected to follow the Academic Affairs Contingency Plan. Students will communicate with instructors to develop alternate plans for course work completion if necessary. No employee would be eligible for catastrophic leave in these cases. If the employee does not have enough leave to cover their time off, and they cannot telework, they would not be paid. Students/Employees are advised that the use of this form constitutes a legal certification that they genuinely isolated themselves for the period that they designate. Completion of this form by persons who did not engage in self-isolation due to flu-symptoms or coronavirus risk is a fraud on the College.
I agree to the following:
I agree.
That as a part of my self-quarantine I have isolated myself during this period of time and have only left my residence when absolutely essential, such as doctor visits;

That I submit this Certification of Illness in lieu of a physician’s note as to my absence from school/work at New River Community and Technical College;

That I fully understand that submission of this Certification of Illness or Quarantine under false pretenses (which would include failure to genuinely self-isolate during the listed times) would constitute a fraud upon the College.
Signature*
This certification of illness or quarantine is only accepted as valid by the College to document an absence of up to two calendar weeks. A physician’s note is required for absences of greater length. Special circumstances may be reviewed by HR.
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