Skip to main content
Menu
Tertiary Navigation
Title IX/SIM
Main navigation
About ETBU
Academics
Admissions
Life on the Hill
Athletics
ETBU Now
Calendars
Events
Hilltop Magazine
Media
News
Where to Give
Brand Standard
2021-2022 Campus Operations
Info For
Current Students
Faculty and Staff
Future Students
Adult Education
Graduate Students
Undergraduates
Alumni
Donors
Online
Parents
Employment
ETBU Health Services
Request Info
Visit ETBU
Apply Now
Give
Employee | Health Services COVID-19 Symptom Report
You must have JavaScript enabled to use this form.
Name
Title
Title
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
First Name
Last Name
ETBU email address
Phone
Is a member of your household also employed at ETBU?
- Select -
Yes
No
Please add the household member's name.
What date were you exposed?
Who exposed you to COVID?
Who is your supervisor?
Select One
- Select -
Employee positive for COVID-19
Employee experiencing symptoms of COVID-19
Employee EXPOSED to someone who has symptoms or someone who is positive for COVID-19
Employee reports someone at home EXPOSED to someone who tested positive or has symptoms
Please select all that apply
Fever (100° F or higher)
Cough
Shortness of breath/difficulty breathing
Headache
Sore throat
New loss of taste or smell
body chills
extreme level of fatigue
body/muscle aches
travel in the last 14 days to any region affected by COVID-19
Other…
Enter other…
What date did your symptoms start?
What date did you have your test?
Where did you have your test?
What date did your symptoms start?
Have you ever tested positive for COVID?
- Select -
Yes
No
Date tested positive for COVID? (documentation required)
Have you been vaccinated for Covid-19?
- Select -
Yes
No
What date did you receive the vaccine?
Please send proof of documentation that you received the vaccine to
healthservices@etbu.edu
.
Main navigation
About ETBU
Academics
Admissions
Life on the Hill
Athletics
ETBU Now
Info For
Title IX/SIM
ETBU Health Services
Request Info
Visit ETBU
Apply Now
Give
