COVID-19 Reporting Form
Informing SHAC of COVID-19 positive test results or diagnosis is strongly recommended in order for PSU to initiate centralized university level responses to protect students, staff, and faculty during COVID-19. Please report if you have been to the PSU campus within the past two weeks.

If you think you have been exposed to COVID-19, please do not complete this form. Call SHAC at 503-725-2800.
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
PSU ID Number (leave blank if you are a contractor)
Best Phone Number to reach you *
What is your current COVID-19 vaccination status? *
If you have been vaccinated, please list which vaccine and the date(s) you were vaccinated. (If you have not been vaccinated, please enter N/A.) *
Current Address where you are living *
Have you been on the PSU campus in the PAST 2 WEEKS - if yes, are you a student, employee, or contractor (check all that apply)? *
Required
If you are a student, are you taking any in person classes at PSU? *
If you are a PSU employee or contractor, which department do you work with? (If you are not an employee or contractor, please enter N/A) *
Are you a PSU athlete, and if yes, which sport? (If you are not a PSU athlete, please enter N/A) *
Do you live in PSU student housing, if yes, where? *
Date of Positive COVID-19 test/diagnosis *
MM
/
DD
/
YYYY
What type of COVID-19 test? *
Are/were you experiencing symptoms of COVID-19? If so, what date/time did they symptoms begin? If no symptoms, please enter N/A. *
If you had a positive COVID-19 test and were SYMPTOMATIC, please list dates, times, and buildings you were in (if you are not aware of your room number/office, please describe your work area to the best of your ability), on the PSU campus, during the 2 DAYS BEFORE your symptoms started and up to your positive test date. If you were not on the PSU campus, please enter N/A. *
If you had a positive COVID-19 test and had NO SYMPTOMS, please list dates, times, buildings, room numbers, and/or offices you were in (if you are not aware of your room number, please describe your work area to the best of your ability), on the PSU campus, during the 2 WEEK timeframe before your positive test. If you were not on the PSU campus, please enter N/A. *
Have you been contacted by a contract tracer? If yes, on what date?
MM
/
DD
/
YYYY
Thank you for completing this form. Someone from SHAC will contact you, by phone, within 24 business hours.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Portland State University. Report Abuse