Student Monkeypox Self-Reporting Portal - pg电子下载 State University-pg电子下载

pg电子下载 State University is dedicated to protecting the well-being of its students, faculty, staff, and campus community. The University requires all students, faculty and staff to inform pg电子下载 officials about any recent travel, possible COVID-19 related exposures, and/or associated illness through the self-reporting form. Thank You!

First Name *

ID Number *

Email Address *

phone Number *

Last Name *

Hometown City *

State/Province *

Country *

Do You Live On Campus (in a Residence Hall) *

Yes

No

Please select your Residence Hall *

List All Buildings Occupied *

Contact with COVID-19

Have you had recent contact with someone who has been diagnosed with COVID-19? *

Yes

No

Please describe your last contact visit with this person.

Have you had recent contact with someone suspected of having COVID-19? *

Yes

No

Please describe your last contact visit with this person.

Are you having flu-like symptoms including fever, cough, or shortness of breath? *

Yes

No

If yes, when did your symptoms start?

Have you been tested for COVID-19? *

Yes

No

If yes, what are your test results or when are your test results expected?

Have you received a COVID-19 vaccine?* *

Yes

No

Which vaccine have you taken?

When did you receive your first dose? (mm/dd/yyyy)

When did you receive your second dose? (mm/dd/yyyy)

Have you received a COVID-19 vaccine booster? *

Yes

No

Which vaccine booster have you taken?

When did you receive your booster dose?(mm/dd/yyyy)

Have you received a second COVID-19 vaccine booster? *

Yes

No

Which vaccine booster have you taken the second time?

When did you receive your second booster dose?(mm/dd/yyyy)

Have you received a 3rd COVID-19 vaccine booster? *

Yes

No

Which vaccine booster have you taken the third time?

When did you receive your third booster dose?(mm/dd/yyyy)

Have you recently traveled in the last two weeks? *

Yes

No

If yes, please list cities, states, and countries.

Have any other pg电子下载 students traveled with you? *

Yes

No

If yes, please list their name(s).

Please give any additional information you feel is pertinent.

Please send a confirmation email to the address below:

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