Student Life

Please take a moment to fill out this voluntary H1N1 virus reporting form. We are asking people that believe they have (or have had) the H1N1 virus to fill out this form. This information will help the Office of Student Life track the H1N1 flu at Naropa University and better provide support to people that are ill. Please note that your personal information will not be shared.

*indicates required field

First Name*
Last Name*
Email
Phone
You are a:*	Student Faculty Staff
You live:*	in Snow Lion Off Campus
H1N1 Virus Questions
Start of flu symptoms (since August 24, 2009, if you were ill prior to this date, please do not fill out this form):
Month: Day
Which symptoms are you/were you experiencing? (check all that apply):
Fever (100+) Cough Sore Throat Nausea Vomiting Diarrhea
Do you/Did you have a support person?
Yes No
If no, would you like someone to contact you (if you are currently ill)?
Yes No
If yes, please select one of the following contact methods: (please make sure that information for the selected method(s) are filled out above)
Phone Email Either
Students Only
If you are currently ill, have you contacted your faculty? (if no, please contact them and let them know that you are ill)
Yes No
Did you return to your family home for the duration of your illness?
Yes No
Enter Security Code:

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