COVID Self Reporting Form Are you reporting yourself as a contact with a positive individual or as having recently tested postive?* Contact with positive individual Positive test case Due to a change in CDC recommendations, possible contacts are no longer required to self-report. Self-reporting is now only for positive test cases. Are you isolating/quarantining at home or on-campus?* At home On campus Date of Positive Test* YYYY slash MM slash DD Please list any known contacts with members of the SAU community Personal InformationName* First Last I am a ...* Student Faculty Staff Date of Birth* MM slash DD slash YYYY Current Age*Please enter a number from 12 to 99.SAU ID Number* It is very important your student ID be entered correctly for faculty members to be notified of your medical leave.Email* Enter Email Confirm Email Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Arkansas County*ArkansasAshleyBaxterBentonBooneBradleyCalhounCarrollChicotClarkClayCleburneClevelandColumbiaConwayCraigheadCrawfordCrittendenCrossDallasDeshaDrewFaulknerFranklinFultonGarlandGrantGreeneHempsteadHot SpringHowardIndependenceIzardJacksonJeffersonJohnsonLafayetteLawrenceLeeLincolnLittle RiverLoganLonokeMadisonMarionMillerMississippiMonroeMontgomeryNevadaNewtonOuachitaPerryPhillipsPikePoinsettPolkPopePrairiePulaskiRandolphSalineScottSearcySebastianSevierSharpSt FrancisStoneUnionVan BurenWashingtonWhiteWoodruffYellOut of StateIf out of state, please select out of state from the bottom of the list.Gender*MaleFemaleOtherRace*White (non-Hispanic)Black (non-Hispanic)HispanicAmerican Indian or Alaska NativeAsian or Pacific IslanderEthnicity*Not Hispanic or LatinoHispanic or LatinoAre you a current SAU student athlete?* Yes No Have you been to SAU University Health Services before?* Yes No If not, please complete the Medical History form here - https://web.saumag.edu/health/history/Vaccination InformationHave you been vaccinated for COVID-19?* No Partially vaccinated Vaccinated - Out of Date Vaccinated - Up to Date Fully vaccinated with booster A patient is vaccinated and up to date if they received their second shot of Pfizer or Moderna in the last 5 months or last two month for Johnson and Johnson. If the last shot was taken before this time period and the patient has not received a booster, then the patient is vaccinated and out of date.Documentation of COVID vaccination Drop files here or Select files Max. file size: 10 MB. Symptoms InformationHave you have any of the following symptoms in the last 24 hours?*YesNoFeverChillsMuscle or body achesHeadachesSore throatNew loss of tasteNew loss of smellCoughDifficulty breathingShortness of breathNauseaDiarrheaFatigueCongestionNo symptomsDate of onset of symptoms MM slash DD slash YYYY Patient comments / concernsHiddenUHS ProcessingHiddenProcessing Decision* Record and data has been reviewed and should be moved to tracking database Do NOT send to tracking database and complete record (in case of incomplete/inaccurate information or avoiding duplication) Send to testing process Hold record for further evaluation (will remain as pending) HiddenPlease select the current isolation/quarantine status to pass to the tracking database.* Quarantine Isolation Fully vaccinated – no symptoms, no quarantine Recently positive – no symptoms, no quarantine required Classroom contact – no symptoms Completed Quarantine Recovered Closed HiddenUHS CommentsHiddenPatient ContactedDateStaffComments HiddenIsolation Day 5 MM slash DD slash YYYY This is auto-calculated based on the earliest of two dates - test or onset of symptoms.HiddenIsolation Day 10 MM slash DD slash YYYY This is auto-calculated based on the earliest of two dates - test or onset of symptoms.HiddenRecord Creation InfoHiddenInitial submitter For use in case user is logged in to uhsadmin account but wants to document who created the entry. This will default initially to the display name of the currently logged in user, or if created at intake it will = patient. But can be edited.HiddenRecord what created at what step Intake Self Reporting Testing Tracking Δ
