COVID-19 Case Notification Form

I am filing this report because: I have tested positive for COVID-19. I have symptoms of COVID-19 AND/OR have not been cleared by the Campus Clear App. I have spent greater than 15 minutes and within 6 feet of someone who has tested positive for COVID-19 OR I have been notified by the Department of Health that I have been directly exposed. Other

If other, please explain:

First Name

Last Name

Phone Number

Date of Birth

City of Permanent Residence

State of Permanent Residence

Indicate your role at DWU StudentCoachStaffGraduate AssistantFaculty

Have you notified your workstudy/supervisor/coach/professors? Yes No. It is your responsibility to notify your workstudy, supervisor, coach, and/or professors.

Please identify any sports or cocurricular activities in which you participate.

Where do you live? On Campus Off Campus

If on campus, enter residence hall and room number:

Date of Symptom Onset (Put N/A if no symptoms)

Have you been tested? Yes No

Have you been tested in the last 90 days? Yes No

If yes, enter date and result of test.

List every area on campus that you have visited starting from 48 hours before symptoms started

A direct contact is anyone who you have been within 6 feet of (masked or unmasked) for greater than 15 minutes 48 hours prior to the onset of your symptoms.

List every DWU-affiliated person that you have been in direct contact with. Please also include date of contact with each person.

Are you currently in isolation/quarantine? Yes No. Please isolate immediately until a DWU Response Team representative has contacted you.

If yes, enter location of where you are isolating/quarantining

Do you need a place for quarantine/isolation? Yes No, I will be off campus. No, I am already isolating/quarantining on campus.

If isolating/quarantining on campus, do you need access to food? Yes. Please read the instructions to order food below No. You have opted out of meal delivery program. You will not be refunded on your meal plan.

This field is intended to catch out spammers - please leave it blank.

COVID-19 Case Notification Form

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COVID-19 Case Notification Form