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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, have been experiencing symptoms, or tested positive for COVID-19. A staff member will be in touch with you regarding next steps depending on your responses.

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First Name: *

Last Name: *

Are you or will you be a Resident Student? *

Yes

Location (city/state) *

Major (online): *

Major: *

Best means of contact: *

Phone

Phone Carrier (i.e. Verizon): *

Phone Number: *

E-mail: *

When was the last time you were on campus? (describe) *

Have you traveled outside of Nebraska recently? *

Yes

Where did you travel? *

When did you return to Nebraska? *

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.)

Have you tested positive for the COVID 19 Virus? *

Yes

Have you been exposed to the COVID 19 Virus? *

Yes

Unsure

Have you received one dose of the Moderna or Pfizer vaccine? *

Yes

Have you received both doses of the Moderna or Pfizer vaccine? *

Yes

Have you received the one dose of the Johnson & Johnson? *

Yes

Have you received the booster vaccine? *

Yes

Date of last COVID Vaccination: *

Year

Month

Day

To help preserve the health of our university community, I will make a list of all CSM faculty, staff and students who I have been within 6 feet of (for 15 minutes or longer) in the 48 hours prior to my positive test and/or symptom development. I understand that someone from CSM will call me to retrieve this information and answer any questions I may have.

I Will

Have you been asked to self-quarantine? *

Yes

If you are experiencing symptoms of the COVID 19 Virus or have been diagnosed with the virus, please respond to the following.

Are you experiencing symptoms of the COVID 19 Virus: *

Yes

Are you seeing a doctor or have you called your primary care provider for guidance? *

Yes

(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.)

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.

*Indicate here if you’ve been tested recently and your results were NEGATIVE.

Yes, I have been tested recently and my results were negative.

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(800) 926-5534

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Omaha, Nebraska 68106-2377

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Health Self Reporting Form

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.

CONTACT US

Connect with us

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Undergraduate Field of Study

Graduate Field of Study

Minors & Certifications

Opportunities & Services

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Health Self Reporting Form

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.

CONTACT US

Connect with us

QUICK LINKS