Self Reporting Illness Form

First name*

Last name*

Student/Employee ID Number

Email*

I am a:*

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

Have you tested for COVID-19? *

Yes

If tested, what were your results?

Have you been in close contact with a COVID-19 positive individual within the past 14 days? *

Yes

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