EIU Employee COVID-19 Isolation & Quarantine Reporting Form

Exposure: If you have been exposed to COVID, follow the current CDC guidelines.

Isolation & Quarantine: You should isolate from others when you have COVID-19. Visit this CDC page for the latest accepted guidelines on isolation and quarantine.

The form below should be used by employees who have tested positive for COVID. Please fill out the form to the best of your ability.

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 EIU Human Resources:

E-mail: lcholloway2@eiu.edu
Fax: 217-581-3614

Name Name * First Last
Department *
E-Number *
Date of Birth Date of Birth * / MM / DD YYYY
EIU Email Address *
Cell or Home Phone Number (whichever is the best contact number for you). Cell or Home Phone Number (whichever is the best contact number for you). * - ### - ### ####
Home Mailing Address Home Mailing Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
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 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 the agency or health department that 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 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
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
I understand that it is my responsibility to contact Dean/Director/Supervisor to discuss my absences and for any further direction. *

I understand that it is my responsibility to contact Dean/Director/Supervisor to discuss my absences and for any further direction. 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.

Employees who fail to comply will be referred to their division Vice President for possible discipline. *

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.

Employees who fail to comply will be referred to their division Vice President for possible discipline. I agree to work with contact tracers, public health officials, and medical representatives, and that if I do not do so, disciplinary action may occur. I do not agree to work with contact tracers, public health officials, and medical representatives, and understand that if I do not cooperate, disciplinary action may occur.
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