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.

If you are completing this report after 4:30pm on Friday 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: