COVID-19 Voluntary Disclosure Form

University of Silicon Valley is asking faculty, staff, and students to utilize this form to voluntarily disclose if they are in self-quarantine or self-isolation. The information will be kept confidential in accordance with HIPAA and FERPA, and will be used to assist the university in tracking employees’ use of sick leave, to help understand the impact to the USV community, and to aid the Santa Clara Health Department in their contact investigations when new COVID-19 cases are identified. For employees, voluntary disclosure will have no implications on their job status.

COVID-19 Voluntary Disclosure Form

I am in self-quarantine because (check one):*
- I have been diagnosed by a health care provider with a positive COVID-19 test.
- I have been diagnosed by a health care provider with COVID-19 WITHOUT a positive test, but based on my symptoms.
- I have NOT been diagnosed by a health care provider with COVID-19, but I do have symptoms of the disease.
- I have NOT been diagnosed by a health care provider with COVID-19, but have been exposed to someone who does have a positive COVID-19 test; however, I am NOT symptomatic.
- I am quarantining for other reasons
If quarantining for other reasons, please explain:
Name (no nicknames)*
First Last
Email*
Cell Phone*
First Day of Quarantine*
MM slash DD slash YYYY
Date Last Time on Campus
MM slash DD slash YYYY
Date of Onset of Symptoms
MM slash DD slash YYYY
Date of Testing
MM slash DD slash YYYY
Location of Testing Site (City/State)
Faculty, Staff, or Student*
Department*
Supervisor or Instructor’s Name*
Current Location (City/State)*
Living in USV housing?*
If Yes, USV Housing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Signature*
- By checking this box and typing my name below, I am electronically signing this COVID-19 Voluntary Disclosure Form
Name*
First Last
Date*
MM slash DD slash YYYY

COVID-19 Voluntary Disclosure Form

COVID-19 Voluntary Disclosure Form

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