RFUMS COVID-19 Faculty/Staff Reporting Form
This form is utilized by Rosalind Franklin University of Medicine and Science faculty and staff to report they are experiencing symptoms, a possible exposure, or have suspected or confirmed cases of COVID-19 (Coronavirus). Faculty and staff 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 Office of Human Resources 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 you should NOT attend work or activities on campus or at an affiliated site until being cleared by Human Resources. If you are in need of immediate assistance please contact 847-578-3266 Monday-Friday 8:30a.m.-4:30p.m., or after hours and on the weekend please contact Campus Safety at 847-578-3288.
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Name
Please select your school or division
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Please choose your work location
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Primary phone number where you can be reached
RFU Email Address
Current home address
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
Please provide a brief description of why you checked the above box(es). (Examples: I am experiencing a fever, cough and respiratory distress which began on DATE or my family member has a suspected case of COVID-19)
Have you or your family member been evaluated by a health care professional related to COVID-19?
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Please list any locations you have traveled to/from in the last 30 days.
Please list any academic or clinical commitments you have in the next 14 days. (Examples: I am scheduled to teach classes at the RFU main campus, or work at a clinical site at hospital X.) As a reminder, please DO NOT attend listed activities until you are given clearance by the Office of Human Resources.
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