COVID-19 Information Form

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Please fill out to the best of your ability:

Name *

Date of Birth *

YYYY

Student or Employee? *

Student

Employee

Grade ( if student)

Best Number to Reach You *

I am filling out this form because: *

I have a confirmed positive COVID test

I have symptoms that could be COVID, but I haven't taken a test or my test results are still pending

I have been exposed (I am a close contact) to a person with a positive or presumed case of COVID

Do you have any of the following symptoms or have you had symptoms in the past 48 hours? Which ones? Including: Fever, chills, cough, shortness of breath/difficulty breathing, muscle/body aches, fatigue, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, diarrhea. (type in n/a if not) *

Date first symptom began (onset date)? (type n/a if no symptoms) *

Was there a known prior contact with a positive or known COVID-19 case? If yes, who? *

If you were on campus in the past 48 hours, what areas were you in and what activities did you participate in? *

If known, please list all possible close contacts starting from 48 hours before symptoms started. A close contact is anyone you were within 6ft of for 15 minutes or more. This would include anyone in the same household. *

Has medical care been sought? If so, was there any alternative diagnosis made? (type n/a if not) *

Date and Location of COVID testing. What was your test result ? (if not tested, type n/a) *

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