EIU Student COVID-19 Isolation & Quarantine Reporting Form

This form should only be utilized by those students who have been ordered by a public health official to isolate as a result of a positive COVID-19 diagnosis or have been required to quarantine as a result of having been exposed to someone who is COVID-19 positive.

Please fill out the form to the best of your ability. Call the EIU Health and Counseling Services - Medical Clinic at 217-581-3013 with any questions.

If possible, please provide documentation of your isolation or quarantine by attaching it to this report. If you do not have documentation, please have your provider or public health official/contact tracer send it to the Medical Clinic:

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
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 been required by a public health official/contact tracer to quarantine as a result of being in contact with an individual who has been tested/diagnosed as COVID-19 Positive. I have been encouraged by a medical professional to self-separate as a result of waiting for a COVID test result to be returned. I have been encouraged by a medical professional to self-separate as a result of being exposed to a positive person, while I wait for contact tracing to contact me.
Please identify those individuals who you believe have exposed you to COVID-19?
Please name/identify the agency or health department which has ordered you into isolation or quarantine. *
Please indicate the date in which your isolation or quarantine is to start. Please indicate the date in which your isolation or quarantine is to start. * / MM / DD YYYY
Please indicate the date in which your isolation or quarantine is to end. Please indicate the date in which your isolation or quarantine is to end. * / MM / DD YYYY
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 or quarantine. 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 COVID-19 contact tracers in a timely manner. Contact tracers work alongside and under the guidance of Dr. Sheila Simons, EIU Professor in the Department of Public Health.

Students who fail to comply will be referred to the Office of Student Accountability and Support and may receive an interim suspension and/or campus ban. *

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 COVID-19 contact tracers in a timely manner. Contact tracers work alongside and under the guidance of Dr. Sheila Simons, EIU Professor in the Department of Public Health.

Students who fail to comply will be referred to the Office of Student Accountability and Support and may receive an interim suspension and/or campus ban. I agree to work with contact tracers, public health officials, and medical representatives, and that if I do not do so, judicial sanctioning may be applied by the university. I do not agree to work with contact tracers, public health officials, and medical representatives, and understand that if I do not cooperate, judicial sanctioning will be applied.