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 Email Phone Number City of Permanent Residence (Hometown) Indicate your role at DWU Student Coach Staff Graduate Assistant Faculty Have you notified your supervisor/coach/professors? Yes No – DWU Response Team will do the notifications. Please identify any sports or cocurricular activities in which you participate (band, choir, theater, student government, etc.) Where do you live? On Campus Off Campus If on campus, enter residence hall and room number: Please complete the following if you have symptoms and/or tested positive. Date of Symptom Onset (Put N/A if no symptoms) List your symptoms Have you been tested? 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 List every DWU-affiliated person that you have been in direct contact (Greater than 15 minutes and within 6 feet) 48 hours before symptoms started 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 OR I am already isolating/quarantining on campus. If isolating/quarantining on campus, do you need access to food? Yes – Meals will be delivered 3 times a day No – You have opted out of meal delivery program.* You will not be refunded on your meal plan. * Submit This field is intended to catch out spammers - please leave it blank.
