COVID-19 Screening and Reporting Tool

Vendor Information

First Name

Last Name

Email

Date of Birth

Phone Number

Reason for visiting campus

Visit Information

Primary Role

Job Title

Contact person at OU

Contact person phone number

Department/College

Building(s) to be visited

Campus

Expected date of arrival to campus/workplace

Travel History

Have you traveled or resided outside of Oklahoma within the last 14 days?

Yes
No

Date you left your primary/previous residence

Date you returned to/arrived in Oklahoma

Select all states traveled

Select all countries traveled

List all cities traveled

Select all modes of travel

Have you spent time on a cruise ship within the last 14 days?

Yes
No

Additional comments regarding travel

Event Attendance

Have you attended an event/entertainment venue/gathering or group of greater than 10 people in the last 14 days? The people in your household do not count towards the 10 people.

Yes
No

Event/Entertainment Venue/Gathering or Group setting

Attendance start date

Attendance end date

Did you wear a mask at all times during the event/entertainment venue/gathering or group?

Yes
No

Were all other participants wearing a mask at all times during the event/entertainment venue/gathering or group?

Yes
No

Did you practice social distancing at all times?

Yes
No

Additional comments regarding event/entertainment venue/gathering or group

Symptom Information

Have you experienced any symptoms within the last 14 days?

Yes
No

Exposure Information

Have you had direct contact with Confirmed (+) COVID-19 within the last 14 days?

Yes
No

Have you had direct contact to someone awaiting COVID-19 test results within the last 14 days?

Yes
No

Have you had direct contact with a person experiencing symptoms of concern for COVID-19 within the last 14 days?

Yes
No

Do you share a household with anyone who has had symptoms of concern for COVID-19 within the last 14 days?

Yes
No

Do you share a household with anyone who has been instructed to Self-Isolate within the last 14 days?

Yes
No

Do you share a household with anyone who has been diagnosed with COVID-19 within the last 90 days?

Yes
No

Select any aerosolizing procedures involved in the exposure

Employee PPE worn at time of exposure

Source wearing mask?

Yes
No

Testing Information

Have you tested POSITIVE for COVID-19 within the last 20 days?

Yes
No

Acknowledgement

The information submitted on this form is complete and accurate to the best of my knowledge.

I acknowledge that this screening tool is being used for clearance to visit campus for the specified reasons and dates stated within this form, based on information I provided. It is not intended for use regarding personal medical evaluation, advice, decisions, and/or treatment. Seek care from your primary care provider or emergency services, as appropriate, for any personal medical needs.

I understand this information is being collected for the purpose of infection prevention and public/employee safety.

I Agree

COVID-19 Screening and Reporting Tool - Vendor