Contagious or Infectious Disease Report

Background Information

Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Name of person(s) about whom you are reporting

Full name of involved person

Please answer the questions below. If you are reporting about someone else, please answer the following questions to the best of your knowledge with that individual's information.

S#: IF self-reporting, provide your S#. IF reporting about another person, provide their S#, if known.(Required) This field is required.

Are you a student or employee?(Required)

Student Employee Neither

This field is required.

For students only. Please provide the course record number (CRN) for class(es) attended. If you're not a student, please enter N/A.(Required) This field is required.

For faculty and staff only. Please provide the department or division for which you work. If you're not either faculty or staff, please enter N/A.(Required) This field is required.

At which campus(es) do you work or attend classes? Please select all that apply.(Required)

Fort Morgan Bennett Burlington Limon Wray Other

You must make at least one selection.

If you indicated "other," please type the location. Otherwise, type N/A.(Required) This field is required.

Have you (or the person whom you're reporting about) been tested for a contagious or infections disease, including COVID-19?(Required)

Yes No

This field is required.

Tell us why you (or the person whom you're reporting about) were (was) tested. Check all applicable.(Required)

COVID-19 Directed by medical provider Symptomatic Exposure/potential exposure to contagious/infectious disease Other

You must make at least one selection.

If you selected "other" related to why you (or the person whom you're reporting about) were (was) tested, please explain below. Type N/A if not applicable.(Required) This field is required.

What were the results of the test? If you (or the person whom you're reporting about) have not been tested, please select "unknown."(Required)

Positive Negative Unknown

This field is required.

Describe the symptoms you (or the person whom you're reporting about) are experiencing. If you indicated "unknown" related to the test results, please also include when you anticipate either testing or receiving the results.(Required) This field is required.

Have you (or the person whom you're reporting about) been directed by a medical professional to self-quarantine, or are you (or the person whom you're reporting about) self-quarantining as a precautionary measure?(Required)

Yes - medical professional Yes - precautionary measure No

This field is required.

When were you (or the person whom you're reporting about) most recently on campus? Provide the pertinent date range.(Required) This field is required.

Where, specifically, were you (or the person whom you're reporting about) most recently on campus? Please tell us which campus(es) and the office(s), activity center(s), classroom(s), and/or other parts of the campus(es) that were visited.(Required) This field is required.

Are you (or the person whom you're reporting about) fully vaccinated against COVID-19?(Required)

Yes - Attached in Supporting Documentation No

This field is required.

Have you (or the person whom you're reporting about) tested positive for COVID-19 within the previous three (3) months?(Required)

Yes - Positive test results attached in Supporting Documents No

This field is required.

Please include other comments here. This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Name of person(s) about whom you are reporting

Supporting Documentation

Submission