COVID Test Screening Form
This form needs to be completed before testing.
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What campus are you on? *
First Name *
Last Name *
Date of Birth *
MM
/
DD
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Gender *
Phone Number *
Race *
Ethnicity *
Street Address *
City *
State *
Zip *
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? *
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