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Self Reporting Illness Form
Self Reporting Illness Form
Self reporting illness form
First name
*
Last name
*
Student/Employee ID Number
Email
*
I am a:
*
-- select an option --
Curriculum Student
Continuing Education Student
Employee
Other
Address
*
City
*
State
*
Zip
*
Phone Number
*
Do you have COVID 19 symptoms (Fever, Fatigue, Body Aches, Cough, Shortness of Breath, New Loss of Sense of Taste or Smell)?
*
Yes
No
Have you tested for COVID-19?
*
Yes
No
If tested, what were your results?
-- select an option --
Positive
Negative
Waiting on Results
Have you been in close contact with a COVID-19 positive individual within the past 14 days?
*
Yes
No
What was the date, time, and location of your last visit on-campus?
*
Additional Comments:
To better serve you, may we contact your instructor(s) to inform them you may need temporary accommodations in the event you are asked to remain off campus for a specified time period?
*
Yes
No
Submit
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