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COVID-19 Student Self Reporting Form
Students:
Please complete this form
ONLY
if you have tested positive for COVID-19. Responses will be submitted to the Vice President of Student Services, and your name and contact information will be shared with the local health department for contact tracing purposes. The health department will contact you to identify others with whom you have had close contact. The identified parties will be notified only that they have been in contact with someone who tested positive for COVID-19; names and identities will not be shared.
Name
*
Required
First
Middle
Last
Student ID #
Please include leading zeros. The full ID # should be 7 digits long.
This can be found on your student ID card.
Address
*
Required
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
- must be mm/dd/yyyy format
*
Required
Date Format: MM slash DD slash YYYY
Phone
*
Required
Email
*
Required
Date of Positive Test
- must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY