COVID-19 Intake Report

COVID-19 Intake Report

This reporting form is used to provide up-to-date guidance for COVID-19 infected persons and close contacts to our UMBC community members. Thank you for helping support our efforts to minimize the spread of this virus and for contributing to the health and safety of this campus.

I am reporting for myself

I am reporting on behalf of another person

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:

*Date of Birth:

*Primary Role:

*Other Role:

*Residential Status:

Status

Select one of the following that best describes your status:

I tested positive for COVID-19/Coronavirus

I have had close contact with someone who has tested positive for COVID-19/Coronavirus *(Close contact means being within 6 feet of someone for more than 15 cumulative minutes in a 24 hour period)

Status Information

*Did you, or do you now have any symptoms?:

Please provide the actual or approximate date you first developed symptoms. If you had no symptoms when you tested, please enter the date that you tested. If you had no symptoms when you tested, but later developed symptoms, please enter the date that you started having symptoms. This is your Day 0, please make a note of it.

Your infectious period starts 48 hours before Day 0 and usually ends by Day 10.

*Were you exposed on campus, present on campus, or are you scheduled to attend class or work on campus during this infectious period?

Provide the actual or approximate date you were most recently on campus:

If you live on campus, please list your community and room number below.

Campus Spaces: List all campus spaces that you have occupied for more than 15 minutes within the past 24 hours. Please specify as much detail as possible, such as a room number, area of that room, any equipment used, etc. Not just which building you may have been in.

If you reside on campus, you should make arrangements to leave immediately and isolate at home. A limited number of on-campus isolation spaces are available for those who cannot do so.

Please select the most appropriate statement:

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:

If you are reporting that you had close contact with someone who tested positive for COVID-19, please list the date you last had contact with that person.

*Were you exposed on campus, present on campus, or are you scheduled to attend class or work on campus in the 10 days since your last exposure?

Provide the actual or approximate date you were most recently on campus:

*Did you, or do you now have any symptoms?:

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

I am up to date (this means that I have at least completed a primary series of shots, AND if eligible, have obtained a booster)

Type of Vaccine:

Pfizer/Moderna - requires 2 doses + booster

Johnson & Johnson - requires 1 dose + Pfizer or Moderna booster

Date of final shot:

Additional Information

Is there any other information you would like to provide? Do NOT enter any urgent medical needs here as this report is not monitored 24/7 nor is it monitored by medical personnel.

characters (700 maximum)

After submitting this form, please check your email for very important, detailed guidance.