COVID Reporting

The University is asking faculty, staff, and students to utilize this form to voluntarily disclose that you have tested positive to COVID-19. The information will be kept confidential in accordance with HIPAA and FERPA and will be used to assist in efforts vital to the safety and well-being of those on campus. Voluntary disclosure will have no implications for your enrollment or job status.

Name & Contact
Your Legal Name*
First Last
Date of Birth
MM slash DD slash YYYY
Phone*
Email*
Affiliation*
- Student
- Employee
Have you been tested for COVID-19 and received a POSITIVE result?*
- Yes
- No
If you have NOT received a positive test result for COVID-19, please select "no" and the survey will end. If you are awaiting a pending test result, please return to this reporting tool after you receive a positive test result.
Test Information
Date of POSITIVE COVID-19 test CONDUCTED (Not the date you received your test results unless it was the same day as you were tested.)*
MM slash DD slash YYYY
Date of POSITIVE COVID-19 test RESULT*
MM slash DD slash YYYY
Type of COVID test (if known)
Location of test (city, county, state)*
Date symptoms started*
MM slash DD slash YYYY
Date of exposure to other COVID positive individual (if applicable)
MM slash DD slash YYYY
Isolation plans*
- I will be leaving campus to isolate at home.
- I am not able to leave campus and will need to isolate on-campus.
- I am not sure yet about my plans and would like to talk to Milligan Health Services about my options.
Contact Tracing
Last date on campus
MM slash DD slash YYYY
Identify buildings and rooms from when you were last on campus:
Who at Milligan have you been in contact with closer than 6-feet for more than 15 minutes from 2 days before you started experiencing symptoms or before you received a positive test if you do not have symptoms. Please list those people below so we can help you and the Health Department make proper notifications.
Date Name Their email or phone Their residence if known

Click the + on the right to add additional people.

Date	Name	Their email or phone	Their residence if known

Name & Contact

Test Information

Contact Tracing