COVID-19 Reporting Form

Submitter Name(Required)

First Last

Submitter Phone(Required)

Submitter Email(Required)

Enter Email Confirm Email

Submitter EMPLID(Required)

I am a....(Required)

Student EMPLID(Required)

Date of positive result (if known)

Date of last attendance in class(Required)

Department(Required)

Example: CHD

Course Number(Required)

Example: 201

Section Number(Required)

Example: N01B

Campus(Required)

Building(Required)

Room Number(Required)

Please provide a roster of students present in class the day the student informed you about testing positive for COVID-19.(Required)

Be sure to include Name, SIS ID and Student Email Address for each student. PDF or Excel file formats are preferred.

Drop files here or

Max. file size: 20 MB.

Date of Positive Results(Required)

Date of Last Activity on Campus(Required)

List all locations visited while on campus(Required)

Campus

Building

Room

Please provide your Class Schedule(Required)

Course Number (ex: 201)

Section Number (ex: N01B)

Campus

Building

Room