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
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First Name
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Your answer
Last Name
*
Your answer
G#
*
Your answer
Missouri Western Email Address
*
Your answer
Cell Phone Number
*
Your answer
Where are you living?
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On Campus
Off Campus
Tell us your situation:
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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?
Your answer
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)
Your answer
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
No
I prefer not to say
Clear selection
Have you been fully vaccinated for COVID-19?
Yes
No
I prefer not to answer.
Clear selection
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