COVID-19 Exposure Form COVID-19 Exposure Form If you are currently experiencing symptoms potentially related to COVID-19 or have been exposed to someone who has tested positive for COVID-19, please complete the following questions:Personal InformationName*Campus ID*Date of Birth* MM DD YYYY University affiliation:*StudentFaculty/StaffCOVID-19 Testing StatusPlease select one:*Tested PositiveTested NegativeAwaiting Test ResultsNot Yet TestedVaccinationHave you received the COVID-19 vaccination?*YesNoDate of initial vaccination* Date Format: MM slash DD slash YYYY Date of final vaccination Date Format: MM slash DD slash YYYY If you are in the population of individuals where only one vaccination is required, please disclose this to Student Affairs or Human Resources when they reach out to you.Pending Test ResultsWhen were you tested?* Date Format: MM slash DD slash YYYY When were you told you would receive results?Recent ExposureHave you been exposed to an individual who has recently tested positive for COVID-19?*YesNoWhen was your contact with the infected person?*For how long were you in contact with the individual?*SymptomsAre you currently experiencing symptoms?*Please refer to the CDC's Symptoms of Coronavirus for more details.YesNoWhen did you start experiencing symptoms?*Contact InformationCell Phone*Email* Residency*On-campusOff-campusAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Residence hall*Evans-Kimmell HallFrank & Anne Oropeza HallKalbfleisch HallPierson HallSummit HallWarrior Row AWarrior Row BYergens-Rogers HallRoom number*DOE Disclosure GuidelinesIn accordance with the guidance from the United States Department of Education, institutions may release personally identifiable information without consent in response to the COVID-19 pandemic if the disclosure is necessary to protect the health or safety of students or others. Such disclosures may only be to appropriate parties such as law enforcement officials, public health officials, trained medical personnel, and parents. Institutions may disclose information without consent if the disclosure is in a non-personally identifiable form and may include notifying the campus community that a member of the community has tested positive for COVID-19, so long as that individual is not identified.