Thank you for taking the time to complete the Illness Report below. Please provide as much information as possible as you may receive a call from a Health, Safety & Wellness team member should more information be required.
Any information provided to us is voluntary and kept strictly confidential. Please do not come to campus is you are feeling unwell. Our COVID 19 Illness Flowchart here provides more information and should answer any questions you may have. Remember to advise your supervisor/instructor if you are unwell. It is recommended that you contact 811 for further guidance.Thank you for keeping our campus a safe place to live, learn and work!Items indicated with an (*) are required.
* First Name
* Last Name
* Employee/Student ID#
* Preferred E-mail Address
* Re-enter your Preferred E-mail Address
* Preferred Phone number
*1. Are you: Faculty Staff Student
If you are a student and unable to complete course work and/or exams due to illness, you should submit the Self-Declaration of Illness form found here. This form should be submitted to your faculty, federated college, or academic unit office.
*2. If you are a student, do you live on campus? No Yes If yes, do you live alone? Yes No
If you share a room with others and have not contacted Housing Services, please contact their front desk as soon as possibe at 306 585 5450 This number is available 24/7
*3. What are you reporting? (please select all those that apply) Illness Rapid Antigen positive test result PCR positive test result
*4. Have you contacted 811? Yes No*If YES, what did 811 instruct you to do?
*5. If you selected “Illness”, what are your symptoms?
*6. If you selected Rapid Antigen positive/PCR positive test result, are you self-isolating? Yes No From: To:
*7. List locations/rooms where you have been on campus in the last 48 hours, if applicable.
*8. Do you wish to receive a call from our Healthy Workplace Advisor for additional supports? Yes No
The University of Regina collects information under the authority of The University of Regina Act and in accordance with the Local Authority Freedom of Information and Protection of Privacy Act and the Personal Information Protection and Electronic Documents Act for purposes of the administration of the University and its programs and services. By responding to this form, you are consenting to the University of Regina using your personal information to complete this report.
