RFUMS COVID-19 Student Reporting Form
This form is utilized by Rosalind Franklin University of Medicine and Science students to report they are experiencing symptoms, a possible exposure, or have a suspected or confirmed cases of COVID-19 (Coronavirus). Students are required to submit this form detailing possible exposure if an immediate family member or resident of their household is experiencing symptoms, suspect, or have a confirmed case of COVID-19.
The information on this form is submitted directly to the Division of Student Affairs and Inclusion for review and a staff member will be in contact with you as soon as possible. It is important to note that if you are filling out this form AND you currently have symptoms or known exposure to a confirmed COVID-19 case you should not report to classes or clinicals until further directions are received from RFU. This form is monitored consistently and students can expect to review an initial response within 12 hours of submission. If you are in need of immediate assistance please contact 847-578-8354 Monday-Friday 8:30am-4:30pm or after hours and on the weekend please contact Campus Safety at 847-578-3288.
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Name
Your answer
Please list your academic program
Allopathic Medicine (MD)
Podiatric Medicine (DPM)
Pharmacy (PharmD)
School of Graduate and Postdoctoral Studies (PhD or MS)
Psychology (PhD or MS)
Clinical Counseling (MS)
Physician Assistant (MS)
Pathologists' Assistant (MS)
Physical Therapy (DPT)
Nurse Anethesia (DNP)
Biomedical Sciences (MS)
Health Administration (MS)
Health Professions Education (MS)
Health Promotion and Wellness (MS)
Nutrition (MS)
Population Health (MS)
Interprofessional Healthcare Studies (PhD)
Other:
Clear selection
Please choose your anticipated graduation year
2020
2021
2022
2023
2024
2025
2026 or beyond
Clear selection
Primary phone number where you are reachable
Your answer
RFU Email Address
Your answer
I currently live
On-Campus Student Housing
Woodlands on Green Bay
Off-Campus
Clear selection
Please list the address of your current location
Your answer
I am reporting
*
possible symptoms of COVID-19
possible exposure to COVID-19
a suspected case of COVID-19
a confirmed case of COVID-19
None
Self
Other Person
possible symptoms of COVID-19
possible exposure to COVID-19
a suspected case of COVID-19
a confirmed case of COVID-19
None
Self
Other Person
Please provide a brief description of why you checked the above box(es). (Examples: I am experiencing a fever, cough and respitory distress which began on DATE or My roommate has a suspected case of COVID-19)
Your answer
Have you been evaluated by a health care professional related to COVID-19?
Yes
No
Clear selection
Please list any locations you have traveled in the last 30 days.
Your answer
Please list any academic or clinical commitments you have in the next 14 days. (Examples, I am scheduled to attend classes at teh RFU main campus, or I am in a clinical rotation at hospital X.) As a reminder, please DO NOT attend listed activities if you have current symptoms or have been directly exposed to a confirmed case of COVID-19. The Division of Student Affairs and Inclusion will esnure you are excused from any required activities for the duration of this time.
Your answer
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