DOCUMENTATION OF COVID-19 TEST RESULTS

Status *

Status Not Completed Completed
Are you a student or employee? *

Are you a student or employee? Student Employee
Instructions for Employees

Employees must submit documentation of COVID-19 test results to Human Resources via this link:
EMPLOYEES DOCUMENTATION OF COVID-19 TEST RESULTS SPRING 2021
Your Information
Name: Name: * First Middle Last
Student ID Number ("A" Number):
Email *
Date of Birth: Date of Birth: * / MM / DD YYYY
Phone: Phone: * - ### - ### ####
Date of COVID-19 test: Date of COVID-19 test: * / MM / DD YYYY
COVID-19 Test Result: *

COVID-19 Test Result: Positive Negative
Location where COVID-19 test was performed (name of physician's office, hospital, testing site, etc.): *
Do you have any symptoms? *

Do you have any symptoms? Yes No
Check all symptoms that apply: *

Check all symptoms that apply: Fever Chills Cough Sore throat Congestion or runny nose Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste and/or smell Nausea and/or vomiting Diarrhea Other Other
Date symptoms started: Date symptoms started: * / MM / DD YYYY
Were you told to quarantine for 5 days? *

Were you told to quarantine for 5 days? Yes No
Please enter date on which quarantine began: Please enter date on which quarantine began: * / MM / DD YYYY
Were you exposed to someone who tested positive for COVID-19? *

Were you exposed to someone who tested positive for COVID-19? Yes No I don't know
If you feel comfortable identifying the person who tested positive please do so below:
How are you attending/teaching class: *

How are you attending/teaching class: On Campus Online Both
Last date you you were physically on campus? Last date you you were physically on campus? * / MM / DD YYYY
Which campus did you attend? *

Which campus did you attend? Middletown Newburgh
Which buildings and rooms did you enter? *
Which class(es) did you attend? *
Name(s) of instructor(s) and/or student(s) present: *
Have any other members of your household tested positive? *

Have any other members of your household tested positive? Yes No
If you feel comfortable identifying the person(s) who tested positive please do so below:
Have you received the COVID-19 vaccine?

Have you received the COVID-19 vaccine? Yes No

If yes, please upload documentation to https://machform.sunyorange.edu/view.php?id=562371
PLEASE UPLOAD COVID-19 TEST RESULTS (PDF, JPG, JPEG, PNG files only) *

Attach Files
Draw your signature into the box below. (Note: If you are under 18 a parent/guardian must sign.)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Thank you for submitting your records.

A member of our staff will review and record the information within the next 1-2 business days. Please contact the Wellness Center if you have any questions or concerns regarding COVID-19 at wellnesscenter@sunyorange.edu.

The Wellness Center Staff

DOCUMENTATION OF COVID-19 TEST RESULTS

DOCUMENTATION OF COVID-19 TEST RESULTS

Instructions for Employees

Your Information

Thank you for submitting your records. A member of our staff will review and record the information within the next 1-2 business days. Please contact the Wellness Center if you have any questions or concerns regarding COVID-19 at wellnesscenter@sunyorange.edu. The Wellness Center Staff

Thank you for submitting your records.

A member of our staff will review and record the information within the next 1-2 business days. Please contact the Wellness Center if you have any questions or concerns regarding COVID-19 at wellnesscenter@sunyorange.edu.

The Wellness Center Staff