Campus Health
Screening Form
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Employee
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Last Name
First Name
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Email
Within the past 5 days, have you been diagnosed with with a communicable illness, e.g., COVID-19, influenza, shingles, monkeypox?
No
Yes
In the past 48 hours, have you experienced any of the following symptoms that you cannot attribute to another health condition?
Fever (temperature of 100.4℉ or chills)?
Unexplained rash
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
No
Yes
Have you been exposed COVID-19 within the past 10 days? If YES and you have NO symptoms, you may enter the campus. You must wear a well-fitting, high-quality mask, at all times, for 10 full days while on campus. Day 0 is the day of your exposure to someone with COVD-19. Continue to watch for COVID-19 symptoms and if you develop symptoms, DO NOT enter campus and contact covidnurse@galencollege.edu
No
Yes
I understand that I
may
be required to wear a well-fitting mask while on a campus located in a high-risk CDC Community-Level. I
will
also be required to wear a well-fitting mask as required by the CDCs quarantine/isolation guidelines. 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.
No
Yes
I certify that all the information and answers to questions herein are true and correct.
No
Yes
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