Dominican University: Campus Reporting Form COVID-19
Dominican is requesting that any individual report to the University any of the following:
1) tested positive for COVID
2) has possible COVID symptoms
3) has had close contact with someone with COVID (regardless of vaccination status)

The purpose of this form is so that we can provide information and guidance. Additionally, we want to be sure that in any situation that may impact campus, Marin County Public Health is aware and can provide assistance and guidance
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Email *
Person Affected *
please tell us if you (student) or someone else in your household has tested positive for COVID19
COVID Source *
Please select which applies to you
Infection/Contact Date *
Please provide the date of your positive test (or) when you first developed symptoms (or) when you had close contact with a COVID positive person.
MM
/
DD
/
YYYY
First Name *
Last Name *
Cell Phone *
write as ###-###-#### Do not use ( )
Academic Major *
What is your academic major
Academic Advisor *
The name of your academic/faculty advisor
On-Campus Building
If you live on-campus, please tell us your building
Clear selection
On-Campus Room #
If you live on-campus, please tell us your room number
Off Campus Address
If you currently live off-campus, please provide us with your address; write as STREET - CITY - STATE - ZIP
County
If you currently live off-campus, please tell us the COUNTY where you are living
Public Health *
Have you or your health care provider been in contact with your county public health department
Other Information *
Please share any other/important information you need us to know
Submit
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