COVID-19 Test Documentation

This form is for submitting COVID test results only.

If you need to submit your COVID vaccination documentation click here.
Covid-19 Test Documentation

Illinois Governor J.B. Pritzker announced an Executive Order on Aug. 26, 2021 that requires all higher education personnel and students be vaccinated for COVID-19. The mandate requires individuals to be fully vaccinated (two weeks out from final shot) by September 19, 2021. Those individuals who are not yet fully vaccinated must submit to weekly COVID-19 testing. This form will allow the college to begin securely collecting weekly test documentation from team members and students. By submitting your weekly test documentation you will remain compliant with this state mandate. Please ensure your weekly testing results match all criteria included below and remember to certify the accuracy of your results by checking the box below.
Name*

First NameLast Name
Role at Lewis & Clark*
Date of Birth*

MonthDayYear
Date
Email Address*
Phone Number*
Please enter a valid phone number.
Have you received a COVID-19 test this week?*

YesNo
Please explain why you did not receive a COVID-19 test this week (ex: "Testing was not completed this week because I was on vacation" or "I was on quarantine this week and could not come to campus, so I did not submit a test result.")
Name of direct supervisor
Date of test*

MonthDayYear
Test results must be submitted every week before Friday at 4:30PM.
I certify this was a diagnostic test. An antibody test will not be accepted.*

I agree
Attach a scan or photo of your COVID-19 test documentation.*

Please make sure your photo/scan is clearly legible and free of glare before uploading.
Cancelof
I understand that under federal law (18 U.S. Code § 1017) it is illegal to fraudulently or wrongfully use the seal of a U.S. department or agency to any certificate or documentation with knowledge that it is fraudulent, and that penalty for breaking this law is imprisonment up to five years. I also understand that submitting or falsifying records or documentation to the college is a violation of personnel policy and/or student code of conduct, which could include discipline up to and including termination of employment and/or expulsion.*

By checking this box I certify the documentation I have provided is not fraudulent.
Should be Empty:

Covid-19 Test Documentation