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COVID-19 Screening Questionnaire
Have you had any of the following in the last 14 days:
Fever (100.4 or higher), chills, sore throat, cough, congestion, shortness of breath/difficulty breathing, unexplained fatigue, muscle pain, headache, unexplained diarrhea, nausea/vomiting, new loss of taste or smell, or other flu-like symptoms?
Knowingly had close contact, without the use of appropriate PPE, with someone who is currently sick with suspected or confirmed COVID-19? (Close contact is defined as ‘contact within 6 feet of an infected person for 15 or more cumulative minutes over a 24-hour period with or without a mask’).
Received notification from public health officials (state or local) that you tested positive for COVID-19?
If you answer "yes" to any of the questions above, you must refrain from coming to campus until you are cleared by a medical provider or unless determined otherwise by the Office of Equity and Compliance (301-387-3037 or firstname.lastname@example.org). (Exception: those who work in the medical/emergency services field who wear PPE when in close contact with suspected/confirmed COVID patients are permitted to come to campus unless they are experiencing symptoms.)
If you believe you may have COVID-19 or have had close contact with a COVID-positive patient, you must refrain from coming to campus and you are strongly encouraged to get tested.
If you have been told to isolate or quarantine, you must refrain from coming to campus until you are cleared through your local health department.
Note: The information collected on this form will be used to determine only whether you are healthy enough to come to campus. The information on this form will be maintained as confidential.
Email Address (used for receipt confirmation only)