EIU Student COVID-19 Isolation Reporting Form (rev. 8/15/22)

This form should only be utilized by those students who have tested positive through the use of a self-administered antigen test or have tested positive through the use of a laboratory PCR test. This form should be submitted within 24 hours of receiving a positive test result.

If you have tested positive using a self-administered antigen test, please isolate from others until you have been in contact with appropriate medical consultation. EIU Health and Counseling Medical Clinic will respond as soon as possible. However, response times may be delayed or limited during evening hours and weekends.

Please fill out the form to the best of your ability. Call the EIU Health and Counseling Services - Medical Clinic at 217-581-3013 Monday - Friday, from 8:00 - 4:30, with any questions.

If possible, please provide documentation of your isolation (e.g. test results) by attaching it to this report:

Email: health@eiu.edu
Fax: 844-256-6402

Name Name * First Last
E Number - please include the "E" *
Date of Birth Date of Birth * / MM / DD YYYY
EIU Email Address - You will only be contacted using your EIU address. *
Please provide your local/Charleston/EIU Address. If you are commuting to EIU, please list the address you are commuting from. Please provide your local/Charleston/EIU Address. If you are commuting to EIU, please list the address you are commuting from. *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
If you live on campus, please indicate the building and room number you live in.
Please indicate the phone number which you use most frequently. Please indicate the phone number which you use most frequently. * - ### - ### ####
Please indicate the public health action you have been required to undertake *

Please indicate the public health action you have been required to undertake I have been required by a medical provider, public health official to isolate as a result of being COVID-19 Positive. I have tested positive from a self-administered rapid antigen test. I have been encouraged by a medical professional to self-separate as a result of waiting for a COVID test result to be returned.
If ordered by an organization to isolate, please name/identify the agency or health department which has ordered you into isolation.
Please indicate the date in which you started experiencing COVID symptoms? Please indicate the date in which you started experiencing COVID symptoms? / MM / DD YYYY
Please indicate the date in which you were tested? Please indicate the date in which you were tested? / MM / DD YYYY
Please indicate the date in which you believe your isolation is to start. Please indicate the date in which you believe your isolation is to start. * / MM / DD YYYY
Please indicate the date in which you believe your isolation is to end. Please indicate the date in which you believe your isolation is to end. * / MM / DD YYYY
If provided to you, please submit any electronic documentation from a public health official, the Illinois Department of Public Health, or your medical provider which verifies that you are to be in COVID-19 isolation. Where possible this should include your beginning and end isolation/quarantine dates.

Attach Files
I request that the EIU Health and Counseling Services send a notice to my academic faculty letting them know I will be absent from class. This notice will be generic and not indicate that I am absent due to Covid. *

I request that the EIU Health and Counseling Services send a notice to my academic faculty letting them know I will be absent from class. This notice will be generic and not indicate that I am absent due to Covid. Yes, I want a notice sent to my faculty and academic advisor. No, I do not want a notice sent to my faculty and academic advisor.
I also understand that it is my responsibility to contact each of my faculty members to discuss my absences, make arrangements for alternative instruction, and how assignments, tests, quizzes, etc. will be handled. *

I also understand that it is my responsibility to contact each of my faculty members to discuss my absences, make arrangements for alternative instruction, and how assignments, tests, quizzes, etc. will be handled. Yes, I understand my responsibility and agree to do so. No, I do not understand my responsibility.
For the safety of the EIU community and to continue mitigating the spread of the COVID-19 virus, all students, faculty, and staff are expected to comply and cooperate with the requests of Health and Counseling Services and the Office of Student Accountability and Support. *

For the safety of the EIU community and to continue mitigating the spread of the COVID-19 virus, all students, faculty, and staff are expected to comply and cooperate with the requests of Health and Counseling Services and the Office of Student Accountability and Support. I agree to work with HCS and SAS. I do not agree to work with HCS and SAS.