The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

BgFFiZUemq5LeArXzZPYdJazPSdvSS7Cwh4FpZgotjRRGfyaBpJBHmUChZFtL4SyLoPMLUodkDL566GC9Bs2VySFWunS4CL57phnuR5oxErAp2fh6FDFJ57ttAIdWD7i

COVID-19 Reporting Form

To assure the health and safety for yourself and our community, please fill out this self-report form to assure that the proper care and resources are provided to you.

Our office hours are 8am-5pm Monday-Friday.

If you are submitting Health Forms outside of these office hours, our staff will be unable to respond until our regular business hours. If this is an emergency, please call 911.

Please click here for after hours urgent care clinics, if needed for other services.

RDS:

Y-M-D H:M:S

RD:

Y-M-D

Is this the first time you have submitted this form, or is this an update?

* must provide value

I am completing this form because: *

* must provide value

I have been tested for COVID-19.

I have been in direct contact with a COVID-19 positive person.

I have symptoms of COVID-19.

I have tested positive for COVID-19.

Results of test?

Negative.

Awaiting Results.

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If you have documentation from your healthcare provider, please upload here:

Upload file

Please provide a photo ID along with your uploaded insurance documenation if applicable.

Upload file

Date test was positive:

M-D-Y

Are you/did you have any of these symptoms (check all that apply)?

* must provide value

Fever

Cough

Sore Throat

Shortness of breath

Loss of Taste or Smell

Chills

Headache

Muscle Aches

Vomiting

Diarrhea

Fatigue

Stuffy/Runny Nose

Other

Please List any Allergies you have

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Please list any Medications you are currently taking

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I am a: *

* must provide value

Student

Faculty

Staff

Vendor/Contractor

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ADH Redcap ID:

My First Name:

* must provide value

My Last Name:

* must provide value

What is your Date of Birth?

* must provide value

M-D-Y

Race / Ethnicity

* must provide value

Black / African American

Native American or Alaskan Native

Asian American

Asian

Caucasian / White

Hispanic / Latino

Native Hawaiian or Pacific Islander

Multi-racial

Prefer not to say

My HSU Email Address:

* must provide value

My Phone Number:

* must provide value

My Campus ID:

* must provide value

Do you live on campus?

* must provide value

Yes

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Where on campus do you reside?

Have you been vaccinated for COVID-19?

* must provide value

Yes

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Vaccination Type

First Vaccination Date

M-D-Y

Second Vaccination Date

M-D-Y

Do you have any additional information you would like to report?

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By submitting this form, I am granting permission to be contacted via email or phone by a member of the NYITCOM @ A-State team concerning the information provided. *
After submitting this form, you should receive an automated email response in your email with instructions and information. Please read this response and follow these instructions. If you do not see an automated response in your inbox after you submit the form, please check your SPAM for your automated response.

* must provide value

I acknowledge

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Verbal consent given instead -

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.