Sickness Registration Form

Name:

Student ID:

Campus:

Status:

NZ Citizen/Permanent Resident
International student

Programme/Course of Study:

Tutor(s):

Where are you staying during your illness:

Illness Details:

Have symptoms of COVID-19
Have been diagnosed with COVID-19
Other (please explain)

Have you been tested for COVID-19:

Yes
No

Do you know your COVID-19 test result:

Positive
Negative
Unknown
Not Applicable

Would you like NorthTec’s Student Health Nurse to contact you?:

If yes, preferred contact method phone, email, zoom appointment

Contact Phone:

Email:

Programme Results