Health Check Form

Please fill out the following COVID-19 symptoms self-screening questionnaire prior to arriving on campus.

Visitation Type (Required)





Birth Date (required)
YYYY-MM-DD format


Identification

Visitation Type

Full Name (Required)

School Email (Required)

Personal Email

Phone Number (Required)
Please put number in the following format: 2539646500

Campus and Contact

Please answer the following questions to indicate where you are traveling and who you will be in contact with.

Campus (Required)

Department(s) Visited

Health Status Screening

Please answer the following questions to determine your health status.

Do you have any of these symptoms that are not caused by another condition? (Required)
  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • Recent loss of taste or smell
  • Sore throat
  • Congestion
  • Nausea or vomiting
  • Diarrhea


Within the past 14 days, have you had contact with anyone that you know had COVID-19 or COVID-like symptoms? Contact is being 6 feet (2 meters) or closer for more than 15 minutes with a person, or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on). (Required)


Have you had a positive COVID-19 test for active virus in the past 10 days? (Required)


Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection? (Required)

Electronic Signature

By checking the boxes below and submitting this form, you are agreeing to an electronic signature and that the information provided is correct to the best of your knowledge. You are also agreeing to having completed the Return to Worksite Coronavirus Education Training Module


4/14/2021

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4/14/2021