Student Positive Case & Close Contact Reporting
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? *
Tell us your situation: *
If you were tested, when did you get tested and where?
Please check all that apply.
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 list all of the people you have been in contact with for the past 14 days, within 6 feet for 15 minutes or more. Include their name, date you interacted with them, their cell phone or email address, if they are a Missouri Western student/staff/faculty, and where you interacted with them.
Please list all of the locations you have been in the past 14 days. Include buildings on campus, dates, and times.
Do you have an off campus location (such as a permanent residence, home of a family member, etc.) you can go to for 14 days of quarantine?
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