COVID-19 Heath Screening Your Information Please enter your information as required below. This will better assist us in contacting you if needed. University Status * Please specify your relation to the universityResident StudentCommuter StudentEmployeeOther University Status Please specify your relationship to the university. If other, select other and enter further details. Employee Department * Specify the department you work in at the university. Last Date on Campus * Vaccination Status Brand of VaccineNoPartiallyFully Please specify the brand of vaccine you have recieved. Vaccine Brand Name Not Applicable/Not VaccinatedPfizerModernaJohnson & Johnson Vaccine Brand Name Please specify the brand of vaccine you have recieved. Full Name * Time In * 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Current Date * Date of Birth * Cell Phone * Health Screening Please answer the below information honestly and to the best of your ability. Do you have any of the following symptoms that are new/different/worse from bassline of any chronic illness? If so, select them below. Fever > 100.4°F New or worsening cough Shortness of breath or difficulty breathing New loss of smell or taste Do you have any of the following symptoms that are new/different/worse from bassline of any chronic illness? If so, select them below. Chills or shivering Headache Sore Throat Runny nose or congestion Fatigue Muscle Aches Vomiting Nausea Diarrhea In the past 14 days, have you had close contact with an individual diagnosed with COVID-19? * Yes No In the past 14 days, have you travelled internationally? * Yes No This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Submit
