Health Reporting Form
Are you reporting for yourself or for another individual?
*
Self
Other (enter name below)
Is the individual currently hospitalized?
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Yes
No
Comments
Information About Sick Individual
First name
*
Last name
*
Email (optional)
Phone number (optional)
Location of prior residence on campus or office or department (if applicable)
Affiliation
*
Student
Other connection
Other connection
Class year
Choose One
Freshman
Sophomore
Junior
Senior
Graduate student
Post-bac premed student
Residence
On-campus - residential student
Off-campus - commuter
Last time on Goucher’s campus
*
Current location
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Have you had contact with other persons positive for COVID-19?
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Yes
Yes
No
Unknown
Tested for COVID-19?
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Yes
No
Date of COVID-19 test
Did you test positive for COVID-19?
Yes
No
Have you been tested for Flu?
*
Yes
No
Were you diagnosed with Flu?
Yes
No
Have you tested positive for any other infectious diseases/illnesses?
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Yes
No
If so, please list:
Have you been instructed by a medical professional to isolate due to symptoms?
*
Yes
No
How many days have you been isolating or limiting your contact with other people?
When did you begin to experience symptoms?
What symptoms have you had so far? (Check all that apply)
Fatigue
Fever (list highest temp if known)
Fever (list highest temp if known)
Reduced Appetite
Body Aches
Shortness of Breath
Pain with breathing
Dry cough
Productive cough (mucous coughed out)
Diarrhea
Headache
Nasal congestion
Sinus Pressure
Sore throat
Sore neck
Swollen Lymph nodes (tender, enlarged glands in neck, behind ears, or in back of head)
Decreased sense of smell or taste
Other
Other
Please list the members of the Goucher student community that you’ve been in contact with in the 48 hours before your illness or diagnosis.
*
Contact is defined as being within six feet of someone for 15 minutes or more during a 24 hour period.
What classes did you attend in the 48 hours before your diagnosis? Please indicate if masks are required in each class listed.
*
Please list the individuals sitting immediately around you (in front of, behind, and on each side)
Comments
Do you consent to us sharing your de-identified information for the purpose of community illness/risk tracking among the Goucher community?
*
Yes
You must check Yes to submit this form.
Do you consent to us sharing your COVID+ diagnosis and contact information with the Baltimore County Health Department? Goucher is required to share this information with the Health Department and all information will be sent in a HIPAA-protected manner.
*
Yes
You must check Yes to submit this form.
If you are human, leave this field blank.
Submit