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. In addition, upon entering the building, your temperature will be checked. While in the building, you will be required to wear a mask and practice social distancing.

User Type

Last Name

First Name

Campus you are visiting today

Phone

Have you experienced any of the following COVID-19 symptoms in the past 48 hours that you cannot attribute to another health condition?

Within the past 14 days:

Have you been exposed to anyone who is known to have laboratory-confirmed COVID-19 without wearing a mask?	NoYes
Have you been exposed to anyone who has symptoms consistent with COVID-19 without wearing a mask?	NoYes
Have you been diagnosed with COVID-19?	NoYes
I certify that all the information and answers to questions herein are true and correct.	NoYes (Choose "Yes" to enable submit button)

Fever or chills	NoYes
Cough	NoYes
Shortness of breath or difficulty breathing	NoYes
Sore throat	NoYes
Loss of taste or smell	NoYes
Congestion or runny nose	NoYes
Fatigue	NoYes
Muscle or body aches/pain	NoYes
Headache	NoYes
Nausea or vomiting	NoYes
Diarrhea	NoYes

COVID-19 Screening Form