Instructions: Please complete this form in the following circumstances:

1 ) You have been contacted and told to self-quarantine by a healthcare provider or a health department as a result of a potential exposure.
2) You have had close proximity exposure to someone with a positive test result (for example, someone in your household). See CDC guidelines for definition of exposure.
3) Someone in your household has had COVID-19 symptoms for three consecutive days

Once you submit this form, do not go on-campus to work until one of the following occurs:     • Your primary healthcare provider indicates that you can go to work (submitting documentation to Human Resources may be required before you can return to work).     • You are contacted by a member of the Safety Department, the Health Center or Human Resources and informed that you can return to work.

If you are completing this form on behalf of someone else, please note your name and contact information in the applicable area at the end of the form.

Employee Information

Are you currently experiencing any of the following COVID related symptoms? (check all that apply)

Name of Person Completing Report (only complete if different from above)