CovidApplications

To protect the health of Galen students, faculty, staff, and visitors, you must be screened for COVID-19 symptoms, using Galen’s COVID-19 self-screening tool, which is based on CDC recommendations. Prior to entering the building, you must provide confirmation that you are approved for access.

User Type

Last Name

First Name

Campus you are visiting today

Phone

Within the past 5 days, have you been diagnosed with COVID-19?	NoYes
In the past 48 hours, have you experienced any of the following COVID-19 symptoms that you cannot attribute to another health condition?
Fever (temperature of 100.4℉ or chills)? Sore throat Congestion or runny nose Night sweats Headache Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches/pain Nausea or vomiting Diarrhea Loss of taste or smell	NoYes
Are you UP TO DATE* on your COVID-19 vaccinations? *UP TO DATE means you have received all recommended COVID-19 vaccines, including any booster dose(s) when eligible.	NoYes
Have you been in close contact* with someone who has or is suspected of having COVID-19 within the past 5 days? *Close contact: being less than 6 feet away from someone who has COVID-19 or COVID-19 symptoms for a cumulative total of 15 minutes or more over a 24 hour period, without wearing a surgical mask.	NoYes
I understand that I will be required to wear a mask while on a campus located in a high-risk CDC Community-Level. I may also be asked to wear a mask when meeting individually with a faculty member, staff member, or student while on a campus with a low or medium-risk level.	NoYes
I certify that all the information and answers to questions herein are true and correct.	NoYes (Choose "Yes" for last 2 prompts to enable submit button)

COVID-19 Screening Form