Infectious Disease Reporting Form
This form is CONFIDENTIAL. Be sure to click "submit" to make your report and clear information from the screen.
This report is about:
Person who received a positive test result for COVID-19
Person who received a positive test result for Monkeypox
Person who has symptoms and has not been tested or is awaiting test results
Person who has been exposed to someone who received a positive test result
Who is making this report:
Myself: I am a faculty or staff member reporting about myself
Myself: I am a student reporting about myself
Supervisor of the individual
Employee (not the supervisor of the individual)
Instructor reporting student
Information about individual with suspected or confirmed COVID-19 or exposure
Name of contact:
Primary role at SIU Carbondale:
Faculty or staff member
Important: If you are not self-reporting, please share as much as you know but do not contact the individual you are reporting about for this information. To protect the privacy rights of our students, faculty and staff, the information you report is considered confidential and should not be shared further. Individuals who may have been exposed to COVID-19 will be contacted directly.
When person was tested:
Where person was tested:
What is the name of the person they were exposed to?
County in which person resides:
I am not sure
What did they test for?
Did this person test positive?
I am not sure
On campus residence location:
Work schedule or class schedule:
Known contacts within last two weeks (names and contact information if available):
Your E-mail address:
Your Phone Number:
Should be Empty: