STAFF COVID-19 HEALTH SCREENING
COVID-19 DAILY HEALTH SCREENING FORM
Name and Date *
building/dept *
Everyone is required to comply with and completing the COVID-19 Screening Questionnaire. It is your responsibility to complete this survey every day of your normal work schedule/obligation before you come to campus or within one hour of arriving on campus. Supervisors will be responsible to ensure their direct reports complete the screening daily.
1. Do you have a temperature equal to or more than 100°F? *
2. Have you experienced any of the following symptoms (not related to chronic, known conditions or seasonal allergies)Symptoms can include: Fever or chills, Cough, New loss of taste or smell , Muscle or body aches, Shortness of breath or difficulty breathing, Fatigue, Headache, Sore throat , Congestion or runny nose, Nausea or vomiting and Diarrhea *
3. Have you tested positive for COVID-19 through a diagnostic test within the past 14 days? *
4. Have you had close contact with confirmed or suspected COVID-19 cases within the past 14 days? *
5. Have you traveled to any of the following states and/or territories for twenty-four (24) hours or longer during the last fourteen (14) days? Alabama, Alaska, Arkansas, California, Delaware, Florida, Georgia, Guam, Hawaii, Idaho, Indiana, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin or internationally? *
If you answered “No” to “ALL” of the above questions, you may proceed to your workplace. If your answer to any of these questions changes throughout the workday, you must contact your supervisor immediately to let them know and leave campus. Please check to confirm you have a mask in your possession available for immediate use: *
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