COVID-19 Screening and Reporting Tool - Visitor


Visitor Information

Visit Information

Symptom Information

Have you experienced any symptoms within the last 10 days?

Exposure Information

Have you had close contact with someone with Confirmed (+) COVID-19 within the last 10 days?
Have you been present for any Aerosol Generating Procedures (AGPs) within the last 10 days?
Is this person a member of your household?

Testing Information

Have you been tested for COVID-19 within the last 10 days?
Have you tested positive for COVID-19 within the last 90 days?

Vaccination Information

Have you received a COVID-19 vaccination?

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.