Report an illness - COVID-19
By submitting this form, you agree that (i) you are voluntarily providing the information included in the form, (ii) the form is not to be used as a request by you for medical treatment, and (iii) all of the information you provide may be disclosed to and used by appropriate university officials, on a need-to-know basis, to address any health and safety concerns of the Lipscomb community.

Your email address will be recorded when you submit this form.
Email address *
Full Name *
Your answer
Phone Number *
Your answer
Role in the Lipscomb Community *
Have you recently traveled internationally? *
If yes, what countries did you visit?
Your answer
Have you been in contact with a person with a laboratory-confirmed case of coronavirus? *
Have you been tested for Coronavirus? (COVID-19) *
If yes, what was the result?
Please provide any additional information that might be helpful in caring for the health and safety of the Lipscomb community:
Your answer
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