Student-Report Isolation/Testing

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SUNY Cobleskill

Student Report of Isolation/Testing

This form is to be used by students to report isolation orders, and to submit supporting documentation. Information submitted will be reviewed by Beard Wellness Center staff.

Student Information

Student Name*

First Name

Last Name

Campus Email*

SUNY Cobleskill ID#*

Cell Phone*

Are you a:*

Residential student living on campus Commuter student living locally

Residential Student Information

Your permanent residence hall*

Room #*

Commuter Information

Local housing address*

Address Line 1

Address Line 2

City

State

ZIP Code

How many other SUNY Cobleskill students live with you?*

SUNY Cobleskill roommate #1*

First Name

Last Name

SUNY Cobleskill roommate #2*

First Name

Last Name

SUNY Cobleskill roommate #3*

First Name

Last Name

SUNY Cobleskill roommate #4*

First Name

Last Name

SUNY Cobleskill roommate #5*

First Name

Last Name

SUNY Cobleskill roommate #6 and others (please list any other SUNY Cobleskill roommates)*

Have you notified your roommate(s) of your current status or a notification from the Department of Health or health care provider?*

Yes No

Permanent Address Information

Permanent home address*

Address Line 1

Address Line 2

City

State

ZIP Code

Permanent Address Phone*

Isolation/Testing Information

In the past 5 days:*

I have been contacted by a Department of Health official or medical provider requiring me to isolate due to my positive Covid-19 test I have tested positive with a self-test

Date of positive test*

Date of start of symptoms*

Residential students are encouraged to complete their isolation at home.

Commuter students may complete their isolation at their local off campus residence or at their permanent home address.

Where do you plan to isolate?*

On campus Off campus at my permanent home address Off campus at my local housing address

Other:

Required: Please submit any documentation you have received from the Department of Health or medical provider confirming the above dates and times.

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Date of notification from DOH/medical provider*