Influenza-Like Illness Notification Form

This form is designed for students who have flu-like symptoms. If you do have flu-like symptoms, please complete this form and submit it electronically by selecting "submit." The form will be sent to Health Services and the Residence Life Office.

Self-Reporting Information

* Required Fields

YOU MUST HAVE Influenza-like symptoms which include:

  • Fever (100° F [37.8°C]) or greater
  • Body aches
  • Runny or stuffy nose
  • Sore throat
  • Cough
  • Headache
  • Chills
  • Fatigue
First Name*
Last Name*
Residence Hall*
Room Number*
Roommate 1
Roommate 2
Roommate 3
E-mail Address*
Cell Phone*
Room Phone*
Date on which you developed flu-like symptoms*
     
Please provide details of your symptoms*
Are you going home or self-isolating yourself for your recovery period?*
   

Self-isolation means to stay away from all other people.  This means staying in your room, leaving only when necessary (i.e. to use the bathroom), and wearing a mask when it is necessary for you to leave your room.  You may not go to the dining hall, student activities, to a friend's room, etc.

On-campus friend who can serve as a resource during your illness*