ADKX Health Screening Form
Self Attestation for Employees and Visitors

This form must be completed for every day you are on-campus and is to be completed prior to beginning your scheduled shift or your visit to campus.
Full Name *
Date *
1. Have you had a recent onset of a dry cough, fever, shortness of breath, muscle aches, or loss of taste/smell? *
2. Have you been in the same room as with a patient with COVID -19 in the last 14 days? *
3. Have you been advised by the health department that you have come into contact with a COVID-19 positive patient in the last 14 days? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy