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Health Self Reporting Form

Please fill out this questionnaire if you have any reason to believe you have been exposed to the COVID-19 virus OR if you have recently traveled outside the United States*. A staff member will be in touch with you regarding next steps depending on your responses.

*Nebraskans returning home from international travel (excluding healthcare workers, commuters, and other unique groups as defined below) should self-quarantine and self-monitor for 14 days upon return/arrival. Those staying less than 14 days in Nebraska should self-quarantine and self-monitor for the duration of their stay. (Nebraska Department of Health and Human Services)

**Note: Only complete the form if you have experienced symptoms, been exposed or have recently traveled outside the United States.

 
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If you have traveled outside of the United States, College of Saint Mary needs to know, so in collaboration with the Douglas County Health Department, we can ensure that you are safe to return to campus.

If you have been exposed to the COVID 19 Virus, please respond to the following.  You will be contacted to discuss potential need to quarantine and either how to best assist you with continuation of your academic studies (for students) or work from home plans (employees.)

If you are experiencing symptoms of the COVID 19 Virus or have been diagnosed with the virus, please respond to the following.  A staff member will call you to discuss how best to cover your work if you are a faculty or staff member or how best to assist you with your classes if you are a student.

(If you do not have a primary care provider in the area, call LaVista CHI clinic at 402-717-9500 and they will provide guidance, and if necessary, be prepared to meet any patient with COVID- 19 procedures.)