COVID-19 Illness/Exposure or Concern Report

Your Name

First Name

Last name

Email
(eg, jsmith6@unca.edu)

Primary phone

University Affiliation

Where are you currently located?
(City, State)

Last Date On Campus

Have you taken a
COVID-19 test?

Are you currently
under medical care
for COVID-19?

.

Requst for Information
Do you need information
on any of the following topics?
(Select all that apply)

General Guidance/Safety Information on COVID-19

Assistance while in Quarantine/Isolation

Information on Mental Health/Counseling Resources

Use of Eligible Paid Leave (faculty/staff)

Other - Please contact me

None

Name of the
Person Submitting the Report

First

Last

Email
(eg, jsmith6@unca.edu)

Contact phone

The following section pertains to the individual being reported.
If there are multiple people, please submit one (1) report for each person.

For assistance with completing the form, please contact: COVIDUpdates@unca.edu

Type of Concern

Person reported testing positive for COVID-19

Person reported being tested for COVID-19 and is awaiting results

Community Concern (e.g. failure to wear a mask, physical distancing, other)

Name
of the person you are concerned about

First

Last

Contact Phone
(if known)

University Affiliation
of the person you are concerned about

Location Observed
(if applicable)

Please share any additional details
you feel are important,
such as the last known date the
person was on campus or in class.