COVID-19 Response Distribution Form
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
BASB - Baseball
BSKM - Basketball Men's
BSKW - Basketball Women's
MGOF - Golf Men's
WGOF - Golf Women's
OTRM - Track and XC Men's
OTRW - Track and XC Women's
SOCM - Soccer Men's
SOCW - Soccer Women's
SOFW - Softball
VOLM - Volleyball Men's
VOLW - Volleyball Women's
ESPO - Esports
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?
*
I have tested positive for COVID-19.
I am presumed to have COVID-19, but have not been tested.
I was directly exposed to COVID-19.
I have concerning symptoms.
Other
A member of the workout pod or roommate(s) has been exposed to someone with COVID19
Date of test, exposure, or start of symptoms
*
-
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
*
Contract Tracing for a Class
Self - Quarantine
Self - Isolation
Heightened-Monitoring
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
Submit
Should be Empty: