Daily Visitor Health Screening
Sign in to Google to save your progress. Learn more
Please list the name(s) of everyone in your group. *
Please provide a phone number should we need to reach you. *
In the last 48 hours, have you or anyone in your group had one or more of these new or worsening symptoms: fever above 100 degrees F, cough, shortness of breath or difficulty breathing, fatigue, chills, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea? *
In the past 10 days, have you or anyone in your group tested positive for COVID-19 OR are you waiting for a COVID-19 test result, due to experiencing symptoms? *
Have you or anyone in your group been designated a contact of a person who tested positive for COVID-19 by a local health department? *
In the last 10 days, have you or anyone in your group traveled using public transportation while being unvaccinated? *
If you answered yes to any of these questions, has everyone in your group met the criteria to return to campus? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Khyentse Foundation. Report Abuse