What campus are you on? *

Staff First Name *

Staff Last Name *

Staff Date of Birth *

Staff Gender *

Staff Phone Number *

Staff Race *

Staff Ethnicity *

Staff Street Address *

Staff City *

Staff State *

Staff Zip *

Staff County *

Do you have Fever *

Do you have Chills *

Experiencing Rigors (a sudden feeling of cold with shivering accompanied by a rise in temperature, often with copious sweating, especially at the onset or height of a fever) *

Myalgia (Muscle pain or ache) *

Headache *

Sore Throat *

Loss of taste *

Loss of Smell *

Cough *

Difficulty Breathing *

Shortness of Breath *

Nausea *

Diarrhea *

Fatigue *

Congestion *

No symptoms *

Clinically diagnosed with pneumonia *

Diagnosed with Acute Respiratory Distress Syndrome (ARDS) *

None *

Have you been in close contact with a confirmed or Probable case of COVID-19 in the past 14 days? *

If yes, what is the Confirmed or Probable Case Name?

Have you tested positive in the past 90 days? *