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 on campus, including the campus grounds and parking lots, you are required to wear a mask and stand at least 6 feet apart from other people.

User Type

Last Name

First Name

Campus you are visiting today

Phone

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)? Cough Shortness of breath or difficulty breathing Sore throat Loss of taste or smell Congestion or runny nose Fatigue Muscle or body aches/pain Headache Nausea or vomiting Diarrhea	NoYes
Within the past 14 days:
Have you been within 6 feet of someone who has laboratory-confirmed COVID-19 for a total of 15 minutes or more over a 24-hour period, without wearing a mask?	NoYes
Have you been within 6 feet of someone who has symptoms consistent with COVID-19 for a total of 15 minutes or more over a 24-hour period, without wearing a mask?	NoYes
Within the past 10 days, have you been diagnosed with COVID-19?	NoYes
NOTE: We are collecting information about the number of students, faculty, and employees who have received the Covid-19 vaccine. This is for informational purposes only and does not impact your ability to enter the building at this time.
Have you received the Covid-19 vaccine?	NoYes
If Yes, have you received both doses?	NoYes
I certify that all the information and answers to questions herein are true and correct.	NoYes (Choose "Yes" to enable submit button);

COVID-19 Screening Form