COVID-19 Illness/Exposure Reporting Form

G Number

Last Name

First Name

E-Mail

Phone Number

Phone

Type of Reporting

In accordance to Policy III.3008.B - Communicable Disease, students and employees must report infection or exposure to a notifiable condition (COVID-19).

I have been diagnosed with or tested positive for COVID-19

I have been in close contact with someone who has COVID-19 (came within 6 feet or was exposed with no protective equipment to cough/sneeze from someone with confirmed COVID-19)

I am experiencing symptoms of COVID-19 (cough, shortness of breath, difficulty breathing, chills, muscle pain, headache, sore throat, loss of taste or smell, diarrhea, fever or temperature greater than or equal to 100.0 degrees Fahrenheit)

I'm unsure of my status and would like to talk to someone about my ability to come on campus

Details

If you are vaccinated, you may state so here. In accordance to Policy III.3008.B - Communicable Disease, students and employees must report infection or exposure to a notifiable condition (COVID-19). By order of the Governor of Texas, any information disclosed here does not mandate testing or vaccination.

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