Student Self-Isolation Form

Students who wish to self-isolate, may do so by completing this form. The results of this form will be sent to Residential Services & Programs, the Registrar's Office and Advising. This information will also be kept on file to help with pandemic response efforts.

Once you return to campus, please complete the student return form.

Not sure if you have a cold, the flu or H1N1? This chart may help.

Please provide information about your campus departure and return plans if you are experiencing flu-like symptoms (fever of 100◦F or above with chills, cough or sore throat. In addition, symptoms of flu can include: runny nose, body aches, headache, tiredness, diarrhea or vomiting).

It is recommended that you plan to return to campus 24 hours after you have been fever free (without fever-lowering medications for 24 hours).

* Email:
First Name
Last Name:
A #:
Home Address:
Date you are leaving campus:
Your professors will be informed that you have left campus because of flu-like symptoms. You are responsible to follow-up with your professors to get the work you will miss and assignments.
Campus Residence Building:
Room Number
Commuting Student?	Yes No
Where are you going?
Home Address
Relative's Name and Address
Friend's Name and Address
Other
Self Isolation on cammpus, Building & Room Number
Note: Students who are ill and self isolating in their room on campus because travel to home is not possible may be asked to relocate from one room to another.