1 Start 2 Complete If you are a school employee who has gotten COVID-19, please complete this form. Name * County of Employment * Job Title/ Position * Are you an AFT-WV member? * Yes No Personal (Non-school system) e-mail * Phone Number * Home Address * Please list the date you tested positive for COVID-19? * Do you believe you contracted COVID-19 at your school or workplace? * Yes No If you answered "yes" to the question above, why do you believe you contracted COVID-19 at your workplace? Were you identified during contact tracing as someone who had been in contact with a COVID-19 positive individual? * Yes No How long were you off work due to your COVID-19 diagnosis? * Do you suffer from any comorbidities or pre-existing conditions (heart issues, asthma, diabetes, obesity, etc)? * Since your COVID-19 diagnosis, have you experienced any long term health effects? If yes, please describe. * Leave this field blank