Covid-19 Reporting Form

Please use this form to report either a positive Covid-19 test result or an exposure to Covid-19.

Employee Name:

CCRI Banner ID:

CCRI Email Address:

Best number to reach you:

Department:

Name of supervisor:

Supervisor email:

Type of issue reported

Positive Covid-19 Test Result

Exposure to Covid-19

If reporting a positive Covid-19 test result, please identify the type of test administered

Please indicate where your test was administered

Vaccination status:

Initial Vaccine Series (2 doses of Moderna or Pfizer, or 1 dose of J&J)

Third dose of approve Covid-19 vaccine booster

Approved Exemption or partial series vaccine (1 shot of Moderna or Pfizer)

Select all that apply

Date of incident:

Names of close contacts: