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
Unknown
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:
*
First Name
Last Name
Phone Number:
If Known
Their Dawgtag:
If known
E-mail address:
If known
Address:
If known
Primary role at SIU Carbondale:
Student
Faculty or staff member
Unknown
Additional information
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:
-
Month
-
Day
Year
Date
Where person was tested:
What is the name of the person they were exposed to?
County in which person resides:
Residence:
*
On-campus
Off-campus
I am not sure
What did they test for?
*
Covid
Monkeypox
Did this person test positive?
*
Yes
No
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 information:
Your Name:
*
First Name
Last Name
Your E-mail address:
*
Your Dawgtag:
Your Phone Number:
*
Submit
Should be Empty: