Covid-19 Reporting

Covid-19 Reporting Form

Please use this form if you suspect you are infected with COVID-19 or have come in contact with someone who is infected. Whether you have been tested or not, you may still complete the form. Students: Please do NOT go to class if you are experiencing symptoms or have tested positive. Please contact Campus Health or CMVSS for assistance. Faculty and Staff: Please notify your supervisor and if you are experiencing symptoms or have tested positive do NOT report to work. Please follow all advice from your healthcare providers.

Involved Parties

Name

First Last

Role(Required)

Cell Phone(Required)

Email(Required)

Others

Add another party

Add Name, Cell Phone, Email for one person per line

Questions

Please answer the questions below (if online or a remote worker, please enter that for location and room number)

Supervisor Name, Email and Phone number

Campus Building, School, or Event where you attended or work

Are you experiencing symptoms of COVID-19?(Required)

Yes I have symptoms

No I do not have symptoms

Have you:(Required)

Been tested and given a confirmed result showing you have COVID-19? (Please upload documentation at the bottom of this form)

Think you have COVID and have not been tested

I came within 6 feet for more than 15 minutes of someone who tested positive

Supporting Documentation

Please upload medical documents below pertaining to COVID-19 testing. 5GB maximum total size.

Attachments require time to upload, so please be patient after submitting this form.

File Upload(Required)

Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf, Max. file size: 100 MB, Max. files: 3.

Name
This field is for validation purposes and should be left unchanged.