COVID-19 Student Self-Report Form
The purpose of this form is to collect information about students who are in quarantine (i.e., awaiting COVID-19 test results or have been in close contact with someone who tested positively for COVID-19) or who are isolating (i.e., tested positively for COVID-19). Completing this form will help University personnel provide you with outreach and support during this time. No information provided in this form will be used for student conduct purposes. NO NEED TO SUBMIT THE FORM MORE THAN ONE TIME.
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First Name *
Last Name *
Student ID Number *
UM Email Address *
Mobile Phone Number (XXX-XXX-XXXX) *
Local Address (e.g., 1234 Landshark Ln. #47, Oxford, MS  38655) or Campus Residential Location (e.g., Stewart Hall 123 or Name of Fraternity/Sorority house) *
As of today, have you received a positive test result for COVID-19? *
If Applicable: On what date was your COVID-19 test administered?
MM
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DD
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YYYY
If you are in quarantine awaiting your COVID-19 test result, where are you staying? Location Name & Address (see format above)
If in quarantine, on what date did you begin to quarantine?
MM
/
DD
/
YYYY
If you are in isolation based on a positive COVID-19 test result, where are you staying? Location Name & Address (see format above)
If in isolation, on what date did you begin isolation?
MM
/
DD
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YYYY
Did Student Health Services or another health care provider give you a notice about being absent from class?
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If Yes, have you emailed a copy of the notice to your faculty members or otherwise notified them of your quarantine or isolation status?
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If you are having difficulty reaching a faculty member or have concerns about faculty response to your notification, please reach out to the Department Chair for the course's academic department. Email the Dean of Students at umdos@olemiss.edu if you are unsure how to do that.
Have you notified family members of your quarantine or isolation status?
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Do you need assistance with notifying family members of your quarantine or isolation status?
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If Yes, please specify how we can assist by providing names, contact information, and any requests.
If there any specific resources or supports you need during this time, please list below and briefly describe how we can help.
Are you comfortable with a UM staff member or C19 Liaison Ambassador calling you via phone to check in on your status, offer support, etc.? If you do not wish to be called, UM staff may still reach out via email to check in. *
Are you comfortable with a UM staff member or C19 Liaison Ambassador offering to contact family if you have asked for that support? *
If you would like a staff member or C19 Liaison Ambassador to check in with you via phone, what frequency would you prefer? We will do our best to maintain the schedule based on available personnel.
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On-Campus Quarantine or Isolation Only: Would you like a Grove Grocery: UM Food Bank delivery?
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