COVID-19 Reporting & Response Distribution

COVID-19 Response Distribution Form
I am a
Student First Name *
Student Last Name *
Student Id Number *
Student Email *
example@example.com
Student Type: *

Campus Center or Online Parkville Gilbert
ID Card deactivation date

Month Day Year
Date
Student Athlete?

No Yes
Sport
Residential Student?

No Yes
Which Campus Residence?

Chesnut Hall Copley Quad Dearing Apartments Gilbert Apartments
Room Number
Student Cell Number

Area Code Phone Number
What are you reporting? *
Date of test, exposure, or start of symptoms *

Month Day Year
Date
End of 14-day quarantine

Month Day Year
Date
Quarantine day 5 - 7 (to receive a PCR test)

Month Day Year
Date
End of 10-day isolation (if symptom/fever free)

Month Day Year
Date
Date of Birth

Month Day Year
Date
Is there any other information you would like to provide?
Letter Writer Name *

First Name Last Name
Letter Writer Email *
example@example.com
Special Notes to Student
Date of Report *

Month Day Year
Date
COVID19 Response Identification *
Date Quarantine or Isolation Ends

Month Day Year
Date
BMZ Sig
Benjamin M. Zibers, MPA
Associate Vice President, Gilbert Campus
Park University | Room 129
92 W Vaughn Ave
Gilbert, AZ 85233
816-673-5822 (Cell) 
Bzibers@park.edu
Discover Park Gilbert
Pronouns: He/Him/His/His/Himself
JRU Sig
Jayme Uden, Ed.D.
Associate Vice President and Dean of Students
Park University | Parkville Campus | Thompson | Room: 203 
8700 NW River Park Drive
Parkville, MO 64152
816-584-6595 (Primary)
jayme.uden@park.edu
Pronouns: He/Him/His/Himself
Should be Empty:

COVID-19 Response Distribution Form