COVID-19 Intake Report


The purpose of this report is to connect affected individuals with information and resources, support our campus response, and minimize spread of the virus to other community members. If you prefer an alternate means of reporting, you may call the UHS support line at (410) 455-2542.


Your Information (Person Reporting)
*Reporter First Name:
*Reporter Last Name:
*Reporter Email:

Affected Individual (Yourself)

Affected Individual (Person you're reporting for)
*First Name:
*Last Name:
*Phone:
*Email:
*Primary Role:
*Other Role:
*Residential Status:

Status
Select one of the following that best describes your status:


Status Information
Provide the actual or approximate date you were tested:

* Have you been on campus since 2 days before your test or before symptoms started, or do you anticipate coming to campus within 10 days?
Provide the actual or approximate date you were most recently on campus:

Provide the actual or approximate date you received confirmation of a positive test result:

Close Contacts: If you are reporting that you tested positive, please list all close contacts names, phone numbers, relationship to you and date of last contact.

Campus Spaces: List all campus spaces that you have occupied for more than 15 minutes within the past 24 hours.

Campus Spaces: List all campus spaces that you have occupied for more than 15 minutes in the past 24-72 hours.

Provide the actual or approximate date you noticed symptoms:

* Have you been on campus since 2 days before your test or before symptoms started, or do you anticipate coming to campus within 10 days?
Provide the actual or approximate date you were most recently on campus:

Provide the date of your last exposure or list “ongoing” if a household member.

* Have you been on campus since your first contact, or do you anticipate coming to campus within 10 days?
Provide the actual or approximate date you were most recently on campus:

Provide the actual or approximate date your close contact received confirmation of a positive test result:
Provide the actual or approximate date your close contact noticed symptoms:

*Have you been on campus within two weeks of your close contact developing symptoms?:
Provide the actual or approximate date you were most recently on campus:



Vaccination Information
Type of Vaccine:
Date of final shot:



Additional Information
Is there any other information that you’d like to provide such as the areas or buildings on campus you accessed during the dates indicated above?:

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