COVID-19 Self Reporting Form

*1. I am completing this form because:

*2. If you have been in direct contact with a COVID-19 positive person, when was the estimated date of exposure?

If this doesn't apply to you, please type N/A in the field.

*3. If you have symptoms of COVID-19, when did you develop noticeable symptoms?

If this doesn't apply to you, please type N/A in the field.

*4. Have you been tested for COVID-19?

*5. I am a:

*6. What was your last day on campus?

*7. First Name:

*8. Last Name:

*9. My Student/Employee ID Number:

*10. My Date of Birth:

*11. My E-mail:

*12. My Phone Number:

A mobile phone number is preferred.

13. Do you have documents from your health care provider? (Examples: COVID-19 screening test result, orders to quarantine, request to report for screening test)

15. Do you have any additional information about your report?