Covid-19 Self-Report Illness Form Please answer the following health questions as part of our screening for COVID-19.Date MM slash DD slash YYYY Name First Last Student ID Number Telephone NumberReporting ExposureHave you had close contact (less than 6 feet for more than 15 minutes without a face covering) in the last 14 days with someone diagnosed with COVID-19? Yes No You are no longer required to quarantine and may remain on campus, but required to wear a mask for 10 days from the date of exposure. If you develop symptoms or test positive, please submit a new report online.Contact with Someone Tested for COVID-19*Have you had close contact (less than 6 feet for more than 10 minutes) in the last 4 to 7 days with someone who has been tested for COVID-19? Yes No Date of Synptoms OnsetWhen did the person you had close contact with start showing symptoms? MM slash DD slash YYYY Date of Last ContactWhen was the last contact you had with this person? MM slash DD slash YYYY SymptomsSince you were last at school, have you had any of these symptoms? (Check all that apply) I Have Not Experienced Any Symptoms Fever Chills Shortness of Breath New Cough Sore Throat New Loss of Taste or Smell Nausea/Vomiting Diarrhea Headache Muscle Pain Fatigue Congestion Runny Nose When did your symptoms start? MM slash DD slash YYYY Tested for COVID-19Since you were last at school, have you tested for COVID-19? Yes No Date Tested MM slash DD slash YYYY Result Are you fully vaccinated?* Yes No Date of First Vaccination (mm/dd/yyyy) MM slash DD slash YYYY Date of Second Vaccination (mm/dd/yyyy) MM slash DD slash YYYY Please share the vaccine that you had: Johnson & Johnson Moderna Pfizer Have you recovered from a documented COVID-19 infection in the last 3 months? Yes No Covid-19 Diagnosis Date mm/dd/yyyy Last Date You Were On Campus: MM slash DD slash YYYY Δ