Return To Campus COVID-19 Clearing Form - Loyola University

COVID Self-Assesment Statement*

Please select from one of the following attest options in the dropdown box below. (Based on Loyola University's Return to Campus criteria.) If you tested negative for COVID-19 AND have not tested positive within the past 21 days, select Option 1. If you have tested positive between December 14th, 2020 and January 4th, 2021, select Option 2. If you tested positive between September 13th, 2020 and December 13th, 2020, select Option 3. If you are unable to attest to any of the options below, please contact Student Health for further direction. OPTION 1: I attest: I am providing a negative COVID-19 test result for myself and that I have NOT had any COVID-19 related symptoms (fever, cough, muscle aches, loss of taste/smell) for the past 10 days. OPTION 2: I attest: I have tested positive within the past 21 days (between 12/14 - 1/4/21); I have NOT had any COVID-19 related symptoms (fever, cough, muscle aches, loss of taste/smell) for the past 10 days and have attached a clearance form from my health care provider. OPTION 3: I attest: I have tested positive more than 21 days ago (between 9/13 - 12/13); I have NOT had any COVID-19 related symptoms (fever, cough, muscle aches, loss of taste/smell) for the past 10 days and have attached a positive COVID-19 result.

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Student ID*

First Name*

Last Name*

DOB*

Please enter as MM/DD/YYYY

Call-Back Number*

Address*

City*

State

Zip Code*

E-Mail Address*

Required Documentation

1. Your student ID or Driver’s License if you have not been issued a student ID. 2. Test Result or Proof of Clearance Form. For those who selected Option 1: Your NEGATIVE COVID Test Result.* Acceptable proof of NEGATIVE COVID-19 test result includes: PDF/JPEG of written or electronic letter/email from healthcare provider/facility clearly stating NEGATIVE COVID-19 result Screen shot of text message from health facility stating NEGATIVE COVID-19 result. For those who selected Option 2: If you have tested positive for COVID-19 between December 14th, 2020 and January 4th, 2021, you will be required to upload a PDF/JPEG of your clearance form from your healthcare provider. For those who selected Option 3: If you have tested positive for COVID-19 between September 13th, 2020 and December 13th, 2020, you will be required to upload a PDF/JPEG of your positive COVID-19 test result. If you have a recent negative test result you may also upload that. If both of the required documents are NOT received, LifeBridge Health will be unable to clear you to return to school.

Return To Campus COVID-19 Clearing Form - Loyola University

**** Required Documentation ****

Required Documentation