COVID-19 self-reporting - COVID-19 health and safety guidance

Campus*

Name*

First Last

If you are completing this form on behalf of a student, please enter their name.

Email*

If you are filling this out on behalf of a student, please enter their email address.

Phone*

Alternate phone (optional)

Local address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current location (if different)*

(where are you, room number, hall, off campus/on campus)

Campus affiliation*

If you are filling this out on behalf of a student, please select student.

Nature of this report*

COVID-19 test type*

Date sample was collected*

Name of COVID-19 case*

Is the close contact a student or employee of the University of Maine System?*

Have you seen a healthcare provider?*

Are you experiencing any COVID-19 Symptoms?*

Are you currently on campus?*

Date you were last on campus*

Additional comments (optional)