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Voluntary COVID-19 Reporting Form

Please complete this form if you have recently tested positive for COVID-19, have been in close contact' with someone who has COVID-19, or if you - or someone close to you – is symptomatic and being tested. (NOTE: This does not apply to everyone who is undergoing required testing before they come back to campus.)

'The Massachusetts Department of Public Health defines “close contact” as:

Living in the same household as a person who has tested positive for COVID-19, OR
Caring for a person who has tested positive for COVID-19, OR
Being within 6 feet of a person who has tested positive for COVID-19 for about 15 minutes, OR
Being in direct contact with secretions from a person who has tested positive for COVID-19 (e.g. being coughed on, kissing, sharing utensils, etc.).

This information will be used to activate the university’s deep cleaning and disinfection efforts, important notifications, and to facilitate contact tracing.

All information will be kept strictly confidential.

Note: All answers with an asterisk (*) are required

COVID-19 Confidential Testing Information

Your Full Name*

You are a*

WPI Student
WPI Faculty member
WPI Staff member
Visitor

Best Contact Information for you:

Mobile Number (Please enter starting with your area code)*

Email address*

Have you been in close contact' with a person who has tested positive for COVID-19?

'The Massachusetts Department of Public Health defines “close contact” as :

Living in the same household as a person who has tested positive for COVID-19, OR
Caring for a person who has tested positive for COVID-19, OR
Being within 6 feet of a person who has tested positive for COVID-19 for about 15 minutes, OR
Being in direct contact with secretions from a person who has tested positive for COVID-19 (e.g. being coughed on, kissing, sharing utensils, etc.).

Yes
No

Have you been tested for COVID-19?*

Yes
No

When was the last date you were physically on the WPI campus?*

What locations (buildings and/or rooms) did you visit when you were last on the WPI campus?* (Please be specific)

If you have any questions, please contact WPI Health Services at 508-831-5520.