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COVID-19 Symptom Questionnaire
COVID-19 Symptom Questionnaire
Please complete this form prior to participating in any on-campus programming.
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First Name
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Last Name
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Email
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Best Phone Number to Contact You
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Have you had a fever over 100 degrees in the past 24 hours?
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No
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Are you having difficulty breathing or shortness of breath?
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Have you recently lost your sense of taste or smell?
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Do you or anyone in your household have a positive COVID-19 test result, or positive clinical diagnosis of COVID-19?
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Have you had close contact with any person known to be positive for, or clinically diagnosed with, COVID-19 in the last 14 days??
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Do you or anyone in your household have a pending COVID-19 test due to illness or exposure?
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Do you have nausea, vomiting, or diarrhea?
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Do you have a sore throat?
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Do you have any unexplained muscle or body aches?
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Do you have a new or unexplained headache?
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Do you have a new or unexplained cough?
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Do you have nasal congestion or a runny nose, not due to other known causes such as allergies?
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No
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Before coming to our campus, please ensure that you are in compliance with the COVID-19 Travel Order which can be found here: https://www.mass.gov/info-details/covid-19-travel-order If you are out of compliance, please stay home.
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I am in compliance
I will stay home
Would you like to make a donation to our COVID-19 Recovery Fund? ($0-$180)
Thu, December 3 2020 17 Kislev 5781
