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COVID-19 Reporting Form

PLEASE READ THIS INFORMATION CAREFULLY TO DETERMINE WHETHER YOU NEED TO SUBMIT THIS FORM.

For the 2022-2023 academic year, we are only asking students to report that they have tested positive for COVID-19 if they need assistance with (A) on-campus isolation housing or (B) excused absences of more than 2 days from classes.

If you test positive or have symptoms:

Individuals who test positive or begin to experience symptoms should utilize the CDC’s COVID-19 Isolation Calculator (and related guidance) to determine how long they will need to self-isolate.

Students who live off campus may self-isolate in their current residence.

Students who live on campus may either self-isolate in their current room or temporarily move off-campus for their self-isolation time. However, MSUM continues to provide isolation housing on-campus. Complete this form if you wish to move to on-campus isolation housing. Please note that the Dean of Students Office will process these requests Monday through Friday from 8am to 4:30pm; if this form is submitted after hours, we will respond to you the following business day. If you need evening or weekend assistance with on-campus isolation housing, after completing this form you may call Housing & Residential Life staff on duty at 701.238.4506.

If you need assistance with excused absences from in-person classes for more than 2 days due to your COVID-19 isolation, complete this form and the Dean of Students Office will assist you. If you will be/have been absent for 1 to 2 days, work directly with your faculty member.

If you have been exposed to someone COVID-positive:

Individuals who have come into contact with an individual who has tested positive for COVID-19 can use the CDC’s COVID-19 Quarantine Calculator and guidance to determine their next steps. A period of quarantine is no longer required unless the exposed individual tests positive or develops symptoms; therefore, MSUM is no longer providing on-campus quarantine housing.

If you are caring for a dependant who has tested positive for COVID:

Please use the Dean of Students Intake form to indicate class absences for more than 2 days.

Completing this Form: Please enter the information requested below. All information you provide is considered voluntary; you are not legally required to provide it. It is expected that any information that you provide is truthful.

By providing this information, you acknowledge that you are submitting private information to University administrators. No adverse enrollment action will be taken against you if you withhold information.

Confidentiality cannot be guaranteed. The information you provide will be used by University administrators within Minnesota State University Moorhead working in collaboration with local and state health officials. This report may also be used by university administrators responsible for reporting data and statistics to Minnesota State system and State of Minnesota officials.

For emergency health and safety concerns, please call 911. Also, MSUM Public Safety is available 24 hours/7 days a week: 218.477.2449.

For information about the response of the University and departments within, please visit our COVID-19 page linked here.

General Information

Student status(Required):

This field is required.

Today's Date(Required):

This field is required.

Student Information

Your First and Last Name

Dragon ID Number (not starID)

DOB (YYYY-MM-DD)

Phone number

Email address

Local/Current Address

Questions

If you have tested positive for COVID-19 and require either on-campus isolation housing or assistance with absences from class for more than 2 days, complete the form below as completely and accurately as possible. The Dean of Students Office will respond during business hours or, if submitting in the evenings or weekends, we will respond on the next business day. If you have questions, please contact the Dean of Students Office at 218.477.2391.

The reason for my report: (Mark all statements that apply.)(Required)

I have tested positive or have symptoms and require on-campus isolation housing I have tested positive or have symptoms and require excused absences from classes for more than 2 days

You must make at least one selection.

Based on the Center for Disease Control (CDC) calculator (linked above), what is the anticipated last date of your isolation?(Required)

This field is required.

Provide the best way to contact you (such as the phone number to call, etc.).(Required) This field is required.

Please type your first and last name here, confirming you acknowledge that you are submitting this reporting form to MSUM Dean of Students Office.(Required) This field is required.

Supporting Documentation

Please provide a copy of the documentation you have received from your medical provider. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.