Covid-19 Reporting Form

Covid-19 Reporting Form

Saint Xavier University
This HIPAA-compiant 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.

Health Center staff will be on-call dring limited hours on weekend; anyone putting in a report after 4:30pm on Friday will receive a call between the hours of 10am - 4pm on Saturday or Sunday.
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
Location:
Location you traveled
Returned to Illinois:

Month Day Year
Please enter the date you returned to Illinois.
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
Please verify that you are human *
Should be Empty: