COVID-19 Self Reporting

COVID-19 Self Reporting

COVID-19 Reporting Status Date

Student / Employee

Student

Employee

First Name*

Last Name*

RAM ID (900#) (Student and Employee)*

Phone Number*

Email Address*

Department*

Division*

Select

Supervisor*

VP*

Reporter Contact Info

Date of Birth (if student)*

Resident?*

Yes

Hall*

Select

Activity / Sports*

Are you a member of any ASU sports team, clubs, student activity etc?

Last day on campus*

Type of Exposure

(If applicable)

From Home

From Work

Out of Town

Exposure Date

(If applicable)

Reported COVID-19 Status*

Positive

Negative

Awaiting Testing Results

Testing to be scheduled

Reporting Vaccination Only

Reporting Vaccination Side Effects

Initial Testing Date*

Type of Test Taken*

Antigen

PCR

Testing Location*

On-Campus

Off-Campus

Initial Test Results*

Positive

Negative

Awaiting Testing 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.

Yes

On what day did you receive the vaccine?**

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

If your vaccine required two doses, on what day did you receive the second dose?

Number of Leave Hours taken for receiving a COVID-19 vaccine:*

Select

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

Yes

On what day did the side effects begin?*

On what day did the side effects end?*

Number of Leave Hours taken due to Vaccine side effects:*

Select

File Upload

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

Drag and drop files here or

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