Covid-19 Reporting Form

Covid-19 Reporting Form

Saint Xavier University
This form should be completed by the person who has tested positive, is experiencing symptoms, or has been exposed to someone with Covid-19.

Only in circumstances where the person cannot report themselves should another person use this form to report on behalf of an employee or student. The person should be aware you are making this report. Only direct supervisors reporting on behalf of their employees, faculty reporting on behalf of their students, or parent/guardians reporting on behalf of their child should use this form.

Those who prefer not to use this form can call the SXU Health Center at 773-298-3712 to report.
My Name *

First Name Last Name
My Email *
example@example.com
Date of Birth: *

Month Day Year
Date
Are you a: *

Student Employee
Student, are you a:

Commuter Resident
Reporting about (mandatory select one): *
Reason for report (mandatory select one): *

COVID-19 positive test result Symptoms suspicious of COVID-19 Exposure to COVID-19
My SXU ID:
My Phone Number *

Area Code Phone Number
If reporting someone else, they are a:
If reporting someone else, their:

First Name Last Name
If you know their Date of Birth:

Month Day Year
Date
If reporting someone else, their SXU ID:
If reporting someone else, their phone number:

Area Code Phone Number
Relationship to person
Should be Empty: