COVID-19 Student Incident Form

Student Incident Form

 

First Name

Last Name

Home Address

Date of COVID 19 Test

Date of COVID 19 Possible Exposure

Phone Number

Student ID Number

Program Department

Advisor

Details of Incident or Exposure (include dates, travel locations, and specific SUSLA campus location

Have you been seen by a primary doctor, clinic, or hospital?

If so, give date of visit

What were the physicians’ recommendations to you?

Date of Hospitalization(s)

Doctors orders after hospitalization(s)