COVID-19 Self-Reporting Form
Student/Staff/Faculty
*
Student
Staff
Faculty
Student ID
*
Staff/Faculty Department
Responder Information
Name
*
First Name
Last Name
Best contact phone number at this time
*
Please enter a valid phone number.
Email
example@example.com
Gender
Male
Female
Gender Non-conforming
Age
Current Address
Current Status
Have you tested positive for COVID-19?
*
Yes
No
Date you were diagnosed
*
-
Month
-
Day
Year
Test date
*
-
Month
-
Day
Year
Isolation/quarantine end date assigned by NDDOH or health care provider
*
-
Month
-
Day
Year
Do you believe you have been exposed or infected?
Yes
No
Do you know where you were exposed or infected?
Yes
No
Describe where you were exposed or infected?
Have you self-isolated?
*
Yes
No
Have you been on campus in any buildings in the past 24 hours and if so, where and which spaces?
*
Clinical Signs and Symptoms
Do you have a fever?
Yes
No
What is your temperature in degrees Fahrenheit?
Are you experiencing a dry cough?
Yes
No
Are you experiencing a sore throat?
Yes
No
Are you experiencing breathing difficulty?
Yes
No
Are you experiencing chest pain?
Yes
No
Have you sought medical care?
Yes
No
If "YES" where:
Primary Care Provider
Hospital
Urgent Care
Where:
Family/Direct Contact Concerns
Have you been identified as a close contact of someone diagnosed with COVID-19, or been notified by the Dept. of Health or a Medical Provider that you are a close contact?
*
Yes
No
What guidance were you given by the Department of Health?
*
Quarantine
Self-Monitor
Do you live in a residence hall?
*
Yes
No
Which residence hall?
*
Please verify that you are human
*
Submit
Should be Empty: