COVID-19: Positive Case Reporting Form
This form should be completed by any campus community member or visitor that has tested positive for COVID-19.

Employees are required to report if they test positive for COVID-19.

Students are strongly encouraged to report if they test positive for COVID-19.

The information provided on this form will be treated as private and shared only with those that need to know.
Email *
The person completing this form is: *
Required
First Name *
Last Name *
Student ID Number (N/A for Staff/Faculty)
Which campus do you primarily attend classes or work? *
Required
Phone number to contact you: *
County where you currently reside *
Required
If "Other" county, please specify the state and county where you currently reside.
What is your local address? (Identify where you are currently living if this is not your permanent home address)
What is your birth date?
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DD
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YYYY
Supervisor's Name (if applicable):
Department you work in (if applicable):
Reason for being tested
Where was your COVID test performed? *
If symptomatic, date symptoms began:
MM
/
DD
/
YYYY
Date you received a positive result:
MM
/
DD
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YYYY
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