COVID Screening Questionnaire
You are required to complete this questionnaire each time you come on campus. If the answer is yes to any of the questions below, you are to vacate the premises immediately, and contact a health professional.
Email *
Today's date *
MM
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DD
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YYYY
Name *
Are you coming to campus as? *
Have you been in close contact with a confirmed case of Covid-19 within the past 14 days? *
Exception: You can check “No” if you have been in a clinical setting or healthcare facility wearing appropriate personal protective equipment.
1 point
COVID-19 Symptoms
• cough, shortness of breath, or sore throat
• fever in the last 48 hours
• loss of taste or smell
• vomiting or diarrhea in the last 24 hours
Are you experiencing any symptom that is NOT related to any underlying condition(s)? *
1 point
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