COVID Reporting Form

If you have tested positive or have been in close contact with someone who tested positive for COVID-19, please fill out the following form.

Name * First Last
Phone Number * - ### - ### ####
Are you a student or faculty/staff? *
Please check all boxes that apply *
I have tested positive with COVID-19 I have not been tested for COVID-19 I have been in close contact with someone that tested positive for COVID-19
What date were you last exposed to someone who tested positive for COVID-19? / MM / DD YYYY
What date did you receive a positive test? / MM / DD YYYY
What date did you begin showing symptoms? / MM / DD YYYY
You are considered in close contact with someone if you fall into any of the following criteria (regardless of vaccination status):

• You were within 6 feet of someone who has COVID-19 for a total of 15 minutes or more within a 24-hour period.
• You provided care at home to someone who is sick with COVID-19.
• You had direct physical contact with the person (hugged or kissed them).
• You shared eating or drinking utensils.
• They sneezed, coughed or somehow got respiratory droplets on you.

If you have been in close contact with an HLGU student or faculty member, please list them below. Otherwise, you may skip this question and submit.