Positive Case & Exposure Reporting Form

Who needs to fill out this form?

If you are a student or an employee who has:

1. Has tested positive on a COVID-19 test - AND/OR
2. Has had possible exposure to someone who has tested positive to the COVID-19 virus - AND/OR
3. Are experiencing new or worsening Symptoms (per CDC) matching those of COVID-19 that cannot be explained by other reasons

Please submit this form and be sure to inform (call or email) your professor(s) or supervisor of your situation and that you have submitted this reporting form.

This information will only be accessed, used, and disclosed in accordance with local and state public health authorities, as well as other testing partners as permitted by law and any other party as authorized/required under FERPA and MDH guidelines.

All fields marked with * are required.

Information Section
* College Affiliation
* (Star ID is required for student or employee)
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* Do you live within a 60 mile radius of any of the campuses (Willmar or Hutchinson)?
Reporting Section
* Have you been on campus in the last 14 days?

(Maximum 500 characters)

500 Characters limit

Which of the following pertains to this self-report:
First dose's name and date
Second dose's name and date
Booster dose's name and date

(Maximum 500 characters)

500 Characters limit

Signature

By entering my name, I certify that all information contained in this report is true and correct, and I understand that someone from the college will be contacting me to gather additional information after I submit this form

*