COVID-19 Information Form (Coronavirus)

K-State Student/Faculty/Staff

This information should be completed by the individual connected to K-State.

Full Name:

K-State Student/Faculty/Staff

This section should also be completed by the individual connected to K-State.

Name

Relationship to University

Wildcat ID Number

Phone number

Email address

Permanent Home Address

Information

The information will be shared with the Office of Student Life, Housing and Dining Services, and Lafene Health Center staff.

Preferred method for being contacted by K-State.(Required)

Phone Email

This field is required.

When will you arrive into the United States? Please provide the date, time, and final airport destination.(Required) This field is required.

What are your housing plans for your required 14 day quarantine when you arrive to your final destination? If planning to use Housing and Dining facilities, please contact them during business hours by calling (785) 532-6453. If you need to contact them outside of business hours, please call (785) 313-3404.(Required) This field is required.

Does the off-campus location of your 14 day quarantine include any other K-State students?(Required)

Yes No

This field is required.

If yes, please provide their names below. This field is required.

What are your housing plans AFTER your 14 day quarantine?(Required) This field is required.

Do you have any dietary restrictions or special accommodation needs? (only if requiring on-campus housing) This field is required.

Please provide your emergency contact information. Please include Name, Relationship to you, City, State, Zip, Phone Number, and Email. This field is required.

Please provide a confidential contact. This may be the same as your emergency contact (only if requiring on-campus housing). A confidential contact is defined as a person you have contact with who typically knows your whereabouts. This field is required.

Are you currently experiencing any cough, fever or other respiratory symptoms? If so, please contact Lafene Health Center immediately at (785) 532-6544 to discuss your symptoms and travel further.(Required)

Yes No

This field is required.

Travel Itinerary Information

If you have a travel itinerary, please attach here. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

K-State Student/Faculty/Staff

K-State Student/Faculty/Staff

Information

Travel Itinerary Information

Submission