INSTRUCTIONS

  • The purpose of the COVID-19 Incident Report is to enable the University to resist the spread of COVID-19 within the campus community, cooperate and comply with the requirements of the Kansas and Johnson County Departments of Health and Environment, and to work with the University’s insurance providers to assist, if appropriate.
  • A written COVID-19 Incident Report is to be completed by any employee, student or campus community member who has tested positive for COVID-19, is a Person Under Investigation (PUI) by health authorities, believes they have been in contact with a person who has tested positive or is a presumed positive case (advised by a physician that they are presumed positive but not tested), or has shown any COVID-19 related symptoms.  The incident report will be routed to Dale Marrant, Vice President of Human Resources and/or David Foose, Dean of Students.

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* 1. Contact Information

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* 4. If you answered yes to question 3 provide the month and day of onset or indicate n/a.

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* 6. If you answered yes to question 5 provide the month and day of test or indicate n/a.

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* 8. If you answered yes to question 7 provide the name of the agency that notified you and the month and day you were notified or indicate n/a.

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* 9. What is the estimated month and day of your exposure to COVID-19? 

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* 10. What is the suspected location of your exposure?

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* 12. If you answered no to question 11 please explain why or indicate n/a.

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* 13. If you answered yes to question 11 please provide the month and day you started self-isolation or self-quarantine or indicate n/a.

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* 14. Please identify any employees, students, or other campus community members that you have been within 6 feet of for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time of isolation.  Please include name, date, and general location of contact, and if you and the person(s) wore masks at all times or indicate n/a if there was no contact within the specified distance and time frame.

https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/appendix.html#contact

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