Self Reporting Form

Please Answer The Following

Do you have Symptoms?*

Yes
No

I Have Symptoms (Check all that Apply)

From the CDC: People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Date When Symptoms Started.*

I have received a positive test result

Date of COVID-19 test

Date you received the positive result

I have been exposed to COVID-19

Date you were exposed

Describe how you were exposed

Exposure is defined as: Someone who was within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to specimen collection) until the time the patient is isolated.

Contact Tracing*

Were you in close contact* with student, faculty or staff members for the previous 48 hours?

Close contact: Someone who was within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to specimen collection) until the time the patient is isolated.

Yes
No

Contact Tracing Names*

It is important that we reach out to these individuals to see if they are experiencing symptoms. Please list all individuals that you can remember.

Names of Person	Phone Number

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Step 1 of 3

Your Information

Please Answer The Following

I have received a positive test result

I have been exposed to COVID-19

Final Questions

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