COVID Form - Anschutz (split with CU Denver, 10/23/20 5pm) Header Image

COVID-19 Self-Reporting



Attention CU Anschutz Medical Campus Users:

CU Anschutz students and employees are not currently required to submit a COVID-19 self-report form. 

If you have been exposed to COVID-19, are experiencing COVID-19 symptoms, or have tested positive for COVID-19, visit the CU Anschutz coronavirus website for guidance. 

Questions? Contact covidquestions@cuanschutz.edu. 

Attention CU Denver Students, Staff and Faculty:

Beginning Friday January 20, 2023, CU Denver staff, students and faculty will not be required to submit a self-report form. 

*If you are in the 1 year EX MBA program, you are still required to submit a form. Please click "next" to submit a self-report form.

Please do not re-self-report for HR-related sick-leave reasons. Please only re-submit a self-report in the event of a new symptomatic event or new test result.

Questions? Contact Public Health Director: Lacey.Klindt@ucdenver.edu 

COVID-19 Self-Reporting

You must choose one in order to properly submit this form

CU Denver COVID-19 Self-Reporting Form

This is NOT the vaccine verification form.  To submit your vaccine verification form go here. 


Beginning Friday January 20, 2023, CU Denver staff, students and faculty will not be required to submit a self-report form.*

*If you are in the 1 year EX MBA program, you are still required to submit a form. Please click "NEXT PAGE" button below to begin filling out a self-report form.


Questions?  Contact the Public Health Response Director, Lacey.Klindt@ucdenver.edu


If you are experiencing difficulties please contact Lacey.Klindt@ucdenver.edu (Denver)

Is this the first time you have submitted this form? (Hidden 9/6/20)
Are you resubmitting this form because you have had a change in COVID-19 symptoms, exposure, or diagnosis? (Hidden 9/6/20)

COVID-19 Self-Reporting

Are you experiencing any of these COVID-19-like symptoms?

  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea
Are you experiencing any of the COVID-19-like symptoms above?*
What date did your symptoms begin?*
Have you been exposed to COVID-19?*
An exposure is having been within 6 feet of a confirmed COVID-19 case for 15 minutes or more.
Are you fully UP TO DATE on your COVID-19 vaccines? (see definition below)*
"Up To Date" means you have received all CDC recommended COVID-19 vaccines, including any booster dose(s) when eligible (2nd booster for those eligible and 50 years +) https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html#:~:text=Up%20to%20date%20means%20a,series%20of%20COVID%2D19%20vaccines
Which brand was the last COVID-19 vaccine you received?*
Date of final dose in primary/original series of the COVID-19 vaccine*
Date of most recent COVID-19 booster (leave blank if n/a)
Have you been tested for COVID-19? (Hidden 9/6/20)
Have you been tested for COVID-19 in the last month? (Hidden 11/25/20)
Have you been tested for COVID-19 in the last 14 days?
Have you been diagnosed with COVID-19? (Hidden 11/25/20)
Diagnosis can be made by any treating healthcare professional, including a telehealth professional.
Have you been diagnosed with COVID-19 in the last 10 days?*
Positive diagnosis can be from a rapid test, PCR test, or medical professional
On what date were you tested for COVID-19?*
Positive diagnosis can be from a rapid test, PCR test or medical professional.

COVID-19 Exposure Information

Have you been within six feet of someone who has been positively diagnosed with COVID-19 for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before their illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) (with or without a mask)?*
Up To Date = you have received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html#:~:text=Up%20to%20date%20means%20a,series%20of%20COVID%2D19%20vaccines. If you have received 1 booster, you are considered up-to-date.
When was this possible exposure, if known?
Have you been back on campus since this possible exposure?*
Are you currently in isolation/quarantine?*

COVID-19 Testing and Diagnosis Information

What date were you tested for COVID-19?
When were you diagnosed with COVID-19?
Who is the healthcare provider who tested you for or diagnosed you with COVID-19?

Self-Quarantine Information

Have you self-quarantined?
When did you begin self-quarantine? (Hidden 11/19/20)
When have you been approved to end self-quarantine? (Hidden 11/19/20)
When did you end self-quarantine? (Hidden 11/19/20)
How did you determine you should self-quarantine? (Hidden 11/19/20)

Campus Presence Information

If you are positive with COVID-19, list CU affiliated close contacts here (anyone you were around at 6 feet or less for 15 minutes or more in the 48 hours before you were symptomatic or diagnosed

Demographics

Your Name*
Date of Birth*
Examples: Arapahoe, Denver, Adams, Jefferson, Douglas.
What is your role at the University?*
If you cannot access university or CU Medicine emails from home, please list your personal email here
EX: Pulmonology, MS1, Pharm1, Facilities, OLAR, Radiology, etc
Are you a "Critical Infrastructure Employee"?*
*You would have received a Critical Infrastructure Employee Certificate if so*
Did you travel internationally after 2019?
Did you travel domestically after 2019?
Have you been directed by the Health Department, health care provider, or campus official to self-quarantine?
Have you been directed by the Health Department or health care provider to self-quarantine? (Hidden 9/6/20)

Employee Information

Are you resubmitting this form because your telework plans have changed? (Hidden 9/6/20)
Direct Supervisor's Name*
Have you been approved by your direct supervisor for temporary telework?

Temporary Telework Information

Why have you been approved by your direct supervisor for temporary telework?
What date did your direct supervisor approve for you to begin temporary telework?
Which computer(s) are you using to connect to the University environment?

Previous Travel - Location 1

Please enter only one location.
When did you travel to the location above? *
When did you return from the location above? *
Purpose of travel*
Did you travel anywhere else after 2019?

Previous Travel - Location 2

Please enter only one location.
When did you travel to the location above?
When did you return from the location above?
Purpose of travel
Did you travel anywhere else after Jan 2021?

Previous Travel - Location 3

Please enter only one location.
When did you travel to the location above?
When did you return from the location above?
Purpose of travel
Did you travel anywhere else after 2019?

Support Information

If you submit this form due to the occurrence of COVID-19 like symptoms, and/or due to receiving a positive COVID-19 test result, you are required to remain isolated until contacted and provided further instructions by the CU Anschutz COVID-19 Team. 

You will be contacted as soon as possible, typically within 24-48 hours from submitting.  

If you DO NOT have any symptoms, and you have had an exposure -- you are still required to submit this form.  You will automatically receive an auto-clearance e-mail with masking instructions.

 If you have any questions please contact Kimberlyn.Cook@cuanschutz.edu 

You may receive auto-instructions or auto-clearances from noreply@formstack.com  . please check your "other" or "spam" or "junk" folders. 

*By submitting this form, you attest that the information you have provided is true and accurate to the best of your knowledge*

COVID-19 Information (Hidden 9/6/20)

Have you been in close contact with an individual(s) diagnosed with COVID-19 ? (Hidden 9/6/20)
Have you been contacted by the Colorado Department of Public Health and Environment (CDPHE) or other governmental agency about being in possible contact with an individual diagnosed with COVID-19? (Hidden 9/6/20)
Have you experienced COVID-19 symptoms but not been diagnosed? (Hidden 9/6/20)
Were you ill during this time, but not diagnosed with COVID-19? (Hidden 9/6/20)
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