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 the United States within the last 14 days?

Yes
No

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

Yes
No

Date you left your primary residence

Date you returned to/arrived in the United States

Date you disembarked from the cruise ship

Select all countries traveled

To select multiple items hold the shift key for adjacent items and ctrl key for separated items.

Did you wear a mask at all times while traveling onboard an airplane, bus, boat, or train and in public?

Yes
No

Additional comments regarding travel

Symptom Information

Have you experienced any symptoms within the last 14 days?

Yes
No

Exposure Information

Have you been within 6 feet for a total of 15 minutes or longer with someone with Confirmed (+) COVID-19 within the last 14 days?

Yes
No

Have you been within 6 feet for a total of 15 minutes or longer with someone awaiting COVID-19 test results within the last 14 days?

Yes
No

Have you been present for any Aerosol Generating Procedures (AGPs) within the last 14 days?

Yes
No

Do you share a household with someone who has been experiencing symptoms of concern within the last 14 days?

Yes
No

Testing Information

Have you been tested for COVID-19 within the last 14 days?

Yes
No

Have you EVER tested positive for COVID-19?

Yes
No

Vaccination Information

Have you received the influenza vaccination for this flu season (September 2020 to present)?

Yes
No

Have you received a COVID-19 vaccination?

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