This form is valid only for today, Wednesday, August 10, 2022

Screening forms are valid only for the day they are requested.
You must complete a new form each day before you come to campus.

Fields with asterisks (*) are required.

First name *

Last name *

Email *

Contact phone number *

Purpose of campus visit *

In the past 48 hours, or since your last visit to a University facility, have you experienced any of the following symptoms? (please check all that apply)

A new fever (100.4 F or higher) or a sense of having a fever?

A new cough that you cannot attribute to another health condition?

New shortness of breath that you cannot attribute to another health condition?

A new sore throat that you cannot attribute to another health condition?

New muscle aches that you cannot attribute to another health condition or that may have been caused by a specific activity, such as physical exercise?

New respiratory symptoms, such as sore throat, runny nose/nasal congestion or sneezing, that you cannot attribute to another health condition?

New chills or repeated shaking with chills that you cannot attribute to another health condition?

New loss of taste or smell that you cannot attribute to another health condition?

New headache that you cannot attribute to another health condition?

New gastrointestinal symptoms, such as nausea, diarrhea or vomiting that you cannot attribute to another health condition?

Have you had close contact in the last 10 days with an individual with a confirmed or presumptive diagnosis of COVID-19? *

Yes

No

Have you traveled via airplane internationally in the last 10 days? *

Yes

No

Have you had a positive COVID-19 test in the past 5 days? *

Yes

No

Privacy notice: The information you provide when filling out this screener will be shared with certain people

• If your answers indicate that you CAN be physically present on campus, a message will be sent to the email you supplied stating that you are cleared to come to campus.
• If your answers indicate that you CANNOT be physically present on campus, your name and your answers will be provided to the Campus Health Center. A nurse practitioner will contact you to determine whether you are cleared to come to campus.

Questions or comments

For health related questions, contact the Campus Health Center at 313-577-5003. For general questions or comments, send a message to the campus restart committee.