Student Housing COVID Questionnaire - Spring 2021
Dear Residents - Please complete this Questionnaire within 72 hours of your arrival move-in/return to on-campus living.

This questionnaire is designed as a tool to help residents have increased awareness of health/safety of self, available resources of the campus, and shared support and expectations around community living. This tool is not meant to take the place of consultation with your healthcare provider or to diagnose or treat conditions. It is provided as an example of self-assessment inquiries that may aid in your knowledge of symptoms. If you're in an emergency medical situation, call 911 or your local emergency number. Information about COVID-19 is constantly changing. And the level of COVID-19 activity varies by community, as does the availability of testing. For current updates on COVID-19 and details on testing and other health measures in your state, check with your local public health agency and visit the CDC website at
Email address *
Resident's First Name *
Resident's Last Name *
Net ID: *
What is your anticipated move-in/return date to Student Housing? *
Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 15 minutes, or had direct contact with their mucus or saliva, in the past 14 days? *
Does the person with COVID-19 live with you? *
In the last 48 hours, have you had any of the following NEW symptoms? Fever of 100 F (37.8 C) or above, or possible fever symptoms like alternating chills and sweating, cough, trouble breathing, shortness of breath or severe wheezing, chills or repeated shaking with chills, muscle aches, sore throat, loss of smell or taste, or a change in taste, nausea, vomiting or diarrhea. *
Please note - These serve as a snapshot of frequent COVID symptoms, but not meant as an inclusive list of all possible symptoms. If you are feeling ill or have have an symptoms related to health concerns, we urge you to reconsider your move-in plans.
Do you have any of the following possible emergency symptoms? Struggling to breathe or fighting for breath even while inactive or when resting. Feeling about to collapse every time you stand or sit up (floppiness or a lack of response in a child under age 2) *
*If you answered yes to any of the questions above, call 911 or your local emergency number. This may be a medical emergency.
Questionnaire - Next Steps?
YES - If you answered yes to any possible symptoms of COVID-19 and/or had close contact or live with someone who has the condition(s) listed:

1. Please inform CSUEB Student Housing ( so we can help support your transition to campus. CSUEB Student Housing will work with you on any accommodations needed to adjust your move-in/return to campus, including providing you different dates. We will also help notify your faculty and campus resources to receive additional resources and class accommodations.

2. Please speak to your health care provider, and they can provide you with consultation for next steps. Student Housing & Residence Life prioritizes your health and safety, and will work with you to make adjustments to provide you the support you need for a successful start to living on-campus.

NO - If you answered no to possible symptoms with this questionnaire and continue to have no symptoms during your anticpated move-in/return to campus, we look forward to helping you settle into your new home. To ensure the safety of yourself and the shared resident community, please review CSUEB's website: Latest Information about COVID-19 and review Student Housing's resident responsibilities.

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This form was created inside of Cal State East Bay.