* Required

Student Report of Exposure to COVID-19

Student First Name*required

Student Last Name*required

Student Preferred Name*required

Student Email*required

Graduation Year*

2022  2023  2024  2025 

Resident Status*

Boarding  Day 

International Student*

Yes  No 

Dormitory Name*required

Please Select…Ammidon HallBatchelder HallCarter HallCutler HallFlagg HallHarman HallHowe HallKravis HallLongman HallPalmer HallRichmond HallTaylor HallWarham Hall

Vaccination Status*

Booster  Fully Vaccinated  Not Fully Vaccinated 

Vaccination Type*

Pfizer  Moderna  Johnson & Johnson  Other-Specify Below 

Specify "Other" Vaccine*required

Have you tested positive for COVID-19 in the last 90 days? *

Yes  No 

Date of Positive Result (mm/dd/yyyy)

Date of last known exposure *required (mm/dd/yyyy)

Source of Contact*

Roommate  Family  Other 

Describe Contact*required

Please send a confirmation email to the address below: