General COVID-19 Case Reporting Form

Visitors, contractors/vendors, students, and non-student spouses/family who have been on a Stanford or SLAC campus and test positive for COVID-19, within 10 days of their visit, must complete this form. This reporting form will assist Stanford in reducing exposure by assessing the need for enhanced cleaning and complying with the state's general building exposure notice requirements.

Name of person completing this form

Stanford-affiliation of the person completing this form

* must provide value

Visitor

Contractor/Vendor

Student

Non-student spouse

Stanford Contact on behalf of the individual

Other

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Phone Number

On what date was the Covid-19 POSITIVE test TAKEN by the individual?

* must provide value

M-D-Y

On what date did the individual begin feeling ill or experiencing symptoms (i.e. fever, cough, shortness of breath, chest congestion, headache, sore throat, muscle aches, loss of taste, loss of smell, nausea, vomiting, diarrhea)?

M-D-Y

What date was the individual last on a Stanford/SLAC site?

* must provide value

M-D-Y

Please enter the buildings the individual entered and the dates they entered them for the LAST 2 DAYS they were at a Stanford facility. Note - if you have trouble locating your building(s) in the dropdowns, please note them in the "Additional location information" question below.

	Building Name	Date in Building
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7.
8.

Do you need to add more buildings?

Yes

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Please enter the buildings the individual entered and the dates they entered them for the LAST 2 DAYS they were at a Stanford facility.

	Building Name	Date in Building
1.
2.
3.
4.
5.
6.
7.
8.

Additional location information (optional)

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