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Student | Health Services COVID-19 Symptom Report
You must have JavaScript enabled to use this form.
Name
First Name
Last Name
ETBU email address
Phone
Are you a graduate assistant?
- Select -
Yes
No
What residence facilities do you live in?
- Select -
Centennial | Male
Centennial | Female
Linebery Hall
Fry Hall
Mabee Housing Complex
Ornelas Residential Center
University Apartments | Male
University Apartments | Female
University Park Row Houses
The Oaks on Grove Houses
Commuter/Off-campus
Do you have roommates?
- Select -
Yes
No
What are your roommates first and last names?
In the last 14 days did you serve at a school?
- Select -
Yes
No
Which school?
Report Type
- Select -
Self-Report
Report by Faculty or Staff
Are you an athlete?
- Select -
Yes
No
Please list your Head Coach
Select One
- Select -
Student positive for COVID-19
Student experiencing symptoms of COVID-19
Student EXPOSED to someone who has symptoms or someone who is positive for COVID-19
Student reports someone in residence facilities or 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
What date did the symptoms start?
What date did you have your test?
Where did you have your test?
Email a copy of your test results to
healthservices@etbu.edu
.
What date were you exposed?
Who exposed you to COVID?
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
.
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