Student Positive Case & Close Contact Reporting

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Please complete this form any time you have been diagnosed with COVID-19 case or have been in contact with someone who has a positive COVID-19 case.

Missouri Western has established a set of policies and procedures to help protect and support our campus community during the COVID-19 pandemic. Your immediate and clear communication is a vital piece of our effective response. By completing this form, you are helping to trace contact, identify spaces that need cleaning, and are promoting the health of others.

Upon completing this form, the Dean of Students will contact you to discuss your plans and what the University can do to support you during this time. If you have concerns about completing this form, please contact the Dean of Students at (816) 271-5991 or studentaffairs@missouriwestern.edu

First Name *

Last Name *

G# *

Missouri Western Email Address *

Cell Phone Number *

Where are you living? *

On Campus

Off Campus

Tell us your situation: *

I have a confirmed case of Coronavirus, COVID-19

I am a close contact of someone who has a confirmed case of Coronavirus, COVID-19 (Within 6 feet for 15 minutes or more)

I am experiencing COVID symptoms.

I am experiencing COVID symptoms and have been advised by the Esry Student Health Center to quarantine until my COVID testing appointment.

Other:

If you were tested, when did you get tested and where?

If you are experienced symptoms, when did they start? (fever, cough, shortness of breathing, difficulty breathing, chills, muscle aches, sore throat, vomiting, diarrhea, or a new loss of taste or smell)

Please check all that apply.

I am an athlete (This does not include esports)

I have a mask

I have a thermometer

I have transportation to take myself to get tested or for medical appointments

I work on campus

I am able to isolate/quarantine off campus for 14 days (at permanent residence, with family or friends, etc.)

Have you had COVID-19 confirmed by testing within the last three months?

Yes

I prefer not to say

Clear selection

Have you been fully vaccinated for COVID-19?

Yes

I prefer not to answer.

Clear selection

Submit

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