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 10 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 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 fully vaccinated?	NoYes
If you are NOT vaccinated: have you had close contact with anyone diagnosed with COVID-19 or thought to have COVID-19, without wearing a mask, within the past 10 days?	NoYes
I understand that I must wear a mask while on campus, except when I’m eating or drinking.	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)
NOTE: If you are fully-vaccinated and have had close contact with someone suspected of having COVID-19, you may enter the building as long as you do not have any COVID-19 symptoms and you wear a mask. The CDC recommends that you get tested within 3 to 5 days. You must notify the COVID Nurse covidnurse@galencollege.edu if you test positive or develop any COVID-19 symptoms, even though you’ve been fully vaccinated.

COVID-19 Screening Form