COVID Report Form – Tropicana Student Living Forms

COVID-19 Report Form

Please complete the information below as accurately and completely as possible.

If you are reporting another individual, please remember to keep all information strictly confidential.

This report is about:(Required)

A person who tested positive for COVID-19, in a laboratory case

A person who has symptoms and may have COVID-19 but has not been tested or results are pending

A person who has been exposed to someone who received a positive test result for COVID-19

Unknown

Who is making this report?(Required)

Self – I am reporting my own confirmed or suspected COVID-19 illness or exposure

Friend

Roommate

Neighbor

Administrative Staff

Other

Are you vaccinated?

Yes

No
Vaccination status determines the protocol for exposure, but is optional for you to provide. If you do not provide your vaccination status, we will have to assume you are NOT vaccinated and will implement the necessary protocol.

Information on Individual Affected by COVID-19

Name of Affected Person(Required)
First Last

Phone Number of Affected Person

Email of Affected Person(Required)

Affected Person Role at Tropicana Student Living(Required)

Student/Resident

Staff – RA

Staff – Administrator/Other

Unknown

Other

If you are NOT self-reporting, please do NOT ask the affected person if they are experiencing these issues. Answer only using information you know right now.

Symptoms of COVID-19 include a wide range of presentations, including but not limited to:

Fever or Chills

Cough

Shortness of Breath or Difficult Breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

Trouble breathing

Persistent pain or pressure in the chest

New confusion

Inability to wake or stay awake

Bluish lips or face

Read more at The CDC Website for COVID Symptoms.

Are there any symptoms present or any signs of illness (now or in the last 48 hours)?(Required)

Was there known prior contact with a Positive or Suspected COVID-19 case?(Required)

Please describe the areas of Tropicana Student Living/campus that the affected individual visited 48 hours prior to symptoms presenting:

If known, please list individuals in possible close contact with the affected individual visited 48 hours prior to symptoms presenting:

What in-person classes or events did the individual attend starting from 48 hours before symptoms started?

What is the estimated number of other individuals impacted?

Has medical care been sought?

Yes

No

Unknown

Was there a lab test with a Positive result for COVID?

Yes

No

Unknown

You may upload your test results
Accepted file types: jpg, png, pdf, jpeg, heic, Max. file size: 80 MB.
You may upload your test results document, as Tropicana uses a confirmed test date as the starting point for the full 10 day isolation. This document is NOT required, and without it, the full 10 day isolation period will begin on the date we receive this report.

Information about YOU

Your Name
First Last

Your Email

Your Phone Number

Please provide any other information you feel is important for us to know

The information provided in this report will be protected and kept private to the full extent possible.

Information will be used by Tropicana Student Living designated officers for Risk Management and to support the health and safety of the Tropicana Student Living communities. Please ensure you have provided accurate information that can be used to help protect others.

Information may also be provided to the local Health Authority.