Student COVID-19 Daily Self-Checklist - Revised
Review this COVID-19 Daily Self-Checklist each day before reporting to class or clinical. If you reply “yes” to any of the questions below, STAY HOME. Contact your healthcare provider for further guidance. If you feel sick during the class or clinical day - inform your instructor and go home.

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Email *
Name *
Do you have a fever (temperature over 100.3⁰F) without having taken any fever-reducing medications? *
Loss of Smell or Taste? *
Muscle Aches *
Sore throat? *
Cough? *
Shortness of breath? *
Chills? *
Headache? *
Have you experienced any gastrointestinal symptoms such as nausea/vomiting, diarrhea, loss of appetite? *
Have you had close contact or cared for someone with COVID-19 within the past 14 days? *
Is an individual within your household currently being evaluated for COVID-19 symptoms or waiting on the results of a COVID-19 test? *
Have you been asked to self-isolate or quarantine by a medical professional or a local public health official? *
By signing this form electronically, I certify that all information on this form is correct to the best of my knowledge. I give my permission for my screen results to be reviewed by the nursing faculty and administration. *
Date *
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