COVID-19 Self Reporting

Student / Employee
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Resident?*
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Are you a member of any ASU sports team, clubs, student activity etc?

Type of Exposure

(If applicable)

(If applicable)

Reported COVID-19 Status*

Type of Test Taken*
Testing Location*
Initial Test Results*
Have you received a COVID-19 Vaccine?*

Please remember to upload documentation (ex. Vaccination Card, Doctor's note, etc.) indicating that you have received the vaccine using the 'File Upload' section at the end of this form.

* If the vaccine you received requires two doses, please indicate the date of the first dose.

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Did you have any severe side effects from a COVID-19 vaccine?*

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Please submit your test results/documentation here. Please also submit your COVID-19 Vaccination documentation here as well.

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