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WAU COVID-19 HEALTH SCREENING QUESTIONNAIRE
PLEASE COMPLETE THIS QUESTIONNAIRE DAILY. READ IMPORTANT SECTION BELOW BEFORE ARRIVING TO CAMPUS EACH DAY.
Please select one:
Employee (FT, PT, Contractor)
NAME (First and Last)
JOB TITLE (If Student, type Student)
DEPARTMENT (If you are a student and do not work on campus, select n/a. For Contractors and Guests, select department you are working for/visiting.)
Biology & Chemistry
Business and Communications
English Writing Center
Health Wellness & Pe
History & Political Studies
Information Technology Services
Inst. Research & Effectiveness
Sch. of Hlth. Prof. Sci.& Wel.
School of Arts & Social Sciences
Student Financial Services
Are you fully vaccinated?
Select Yes if you received both doses of a vaccine (e.g. Pfizer or Moderna), or a one dose vaccine (e.g. Johnson & Johnson).
Do you have any symptoms such as: (Cough, Shortness of breath or difficulty breathing, Fever, Chills, Runny nose or new sinus congestion, Muscle pain, Headache, Sore throat, Fatigue, New gastrointestinal symptoms, and/or New loss of taste or smell)?
If yes to above question, please explain. (Please read IMPORTANT section below.)
Within the past 14 days, have you been in direct contact with someone who was diagnosed with COVID-19, or had COVID-19 symptoms?
If yes to above question, please explain (timeframe of contact, & read IMPORTANT section below).
Have you been tested (within the past 14 days)?
Did you test positive for COVID-19 (within the past 14 days)?
Waiting for results
If Yes, when did you test positive for COVID-19? (SKIP if previous answer is No)
If your body temperature is at or above 100.4 degrees Fahrenheit (38.0 degrees Celsius), and/or you are experiencing any of the symptoms listed above, please contact your healthcare provider via phone first. Please do not come to campus until a physician issues a certificate of clearance regarding COVID-19.
Only temperatures above 100.4 degrees Fahrenheit (38.0 degrees Celsius) will be recorded and stored in the employee confidential medical file.
An employee sent home with a fever and/or other symptoms can return to work when:
1. He or she has had no fever for at least 24 hours without taking medication to reduce fever during that time; AND
2. Any symptoms (cough, shortness of breath, other symptoms) have improved, AND
3. At least ten days have passed since symptoms began.
The employee may return to work earlier if a doctor confirms the cause of the employee's fever or other symptoms is not COVID-19, and provides a written release for the employee to return to work.
If you are experiencing symptoms, or have been in direct contact with someone diagnosed with COVID-19, or had COVID-19 symptoms, please contact Human Resources at
or (301) 891-4010 before arriving to campus.
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This form was created inside of Washington Adventist University.