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Daily Self-Screening for Visitors
Please submit this form daily before coming to campus. The form is date stamped upon submittal.
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* Indicates required question
Email address (or N/A)
*
Your answer
LAST Name
Your answer
FIRST Name
Your answer
Are you experiencing a cough or difficulty breathing (for those with allergies or asthma change from baseline)?
*
Yes
No
Do you show any of the following symptoms this morning: fever, new-onset headache, vomiting; diarrhea; sore throat?
*
Yes
No
Are you awaiting COVID-19 test results?
*
Yes
No
In the past 10 days, have you been in contact with anyone who is awaiting test results or confirmed diagnosed with COVID-19, or are you living in the same residence with someone who has COVID-19 symptoms? (Please see DOH guidelines for exposure).
*
Yes
No
Have you traveled out-of-state in the past 10 days?
Yes
No
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