COVID-19 Reporting Form

COVID-19 POSITIVE RESULT Reporting Form

Saint Xavier University
This HIPAA-compliant form should be completed by the person who has tested positive. Only in circumstances where the person cannot report themselves should someone else report on their behalf. The person should be aware you are making this report.

If you are symptomatic or have been exposed, please call the Health Center at 773-298-3712 or email Care Coordinator Anne Eastman-Kuziela at eastmankuziela@sxu.edu.

If you are completing this report outside of business hours you will be contacted the next business day. Please wear a mask and stay home/in your room until you have been contacted.
Name *

First Name Last Name
E-mail *
example@example.com
Date of Birth *

Month Day Year
Date
Are you a: *

Student Employee
On or Off Campus:

Resident Commuter
Reporting About: *

Myself Someone else
Reason for Report (mandatory must select one): *

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

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

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:
Please enter a valid phone number.
Relationship to the person: *
Please verify that you are human *
Should be Empty:

COVID-19 POSITIVE RESULT Reporting Form