Charles E. Schmidt College of Medicine
Florida Atlantic University
777 Glades Road, BC-71
Boca Raton, FL 33431
(561) 297-4828
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M1 Student COVID-19 Reporting Form

If you see this don't fill out this input box.

Subject Information

*Student's Full Name:

*Best Contact Number:

*Email Address:

Incident Information

Are you vaccinated against COVID-19 (2 shots if Pfizer or Moderna; 1 shot if J&J)?

Have you received a COVID-19 booster?

*Date of potential exposure to COVID-19, development of potential symptoms of COVID-19, or testing positive for COVID-19:

Were you wearing a mask during the potential exposure?

If yes, what type of mask?

Were you wearing a face shield?

Was the patient/person who has COVID-19 that you were potentially exposed to wearing a face mask that covered their nose and mouth adequately?

Were you within 6 feet of the person/patient who has been diagnosed with COVID-19?

If so, how long was the exposure (in hours and/or minutes)?

*Name of current courses (type N/A if on a school break):

*Name of current course director(s) (type N/A if on a school break):

Which of the following clinical sites will you be rotating at during the next two weeks? (To select more than one site, hold the control button down and select all applicable sites.)

Did you inform one of the deans of student affairs (Dr. Caceres or Dr. Gundersen)?

Have you already contacted FAU Student Health Services at 561-297-3512?