Illness Reporting Form

Illness Reporting Form

You are being asked to complete this form to help contain the spread of COVID and COVID-like illness within the Southeastern Oklahoma State University community.
By completing this form, you acknowledge that
1. What is contained in it is accurate to the best of your ability
2. I understand I will be contacted by an employee of SE to gain more information to assist us with appropriate care measures for you and illness tracking within our campus community
3. We may use the information to notify your work supervisor and/or professors on the SE campus, in general terms, regarding the need to take a medical absence until such time it is deemed appropriate to return to campus safely.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email *
example@example.com
Are you considered: *

Student Faculty Staff
Do you live on campus? *

Yes No
Did you attend work or class during the time you were having symptoms? *

N/A Yes No
Please check all the appropriate boxes. I am: *

an SE student-athlete Dancer Cheerleader Aviator Color Guard Concurrent High School student N/A
I am completing this form because: *

I completed my self-assessment required before reporting to campus and noticed I had some of the symptoms I was diagnosed with COVID and have been instructed to isolate at home I was exposed to or engaged in behavior that has prompted officials to advise me to quarantine at home at this time I am unsure if my situation warrants completion of this form and would like to be contacted to discuss my special considerations and what steps I should take
Should be Empty: