COVID-19 Self-Assessment

If you are a vendor or visitor please use the form below. If you are a faculty, staff, or student please click here.

Disclosure Statement for Self-reporting of COVID-19 Symptoms: As a part of the individual responsibility to help prevent the spread of the COVID-19 virus, individuals are expected to conduct a daily check and self-report using an app provided by the University. The data is for the purpose of campus health and safety. The data will not be commingled with personnel or student records and shall not be used for any health plan purposes. If someone reports symptoms or a positive test, the law requires it be shared with the local health department. For purposes of contact tracing, names will not be provided when alerting others who may have come in contact with the individual who has reported symptoms or a positive test.

Vendor/Visitor Self-Assessment Form

Your Information

Self-Assessment

Please indicate any symptoms that have started, or gotten worse, within the past 48 hours: *

Chills or shakes with chills
  
Congestion/Runny Nose
  
Coughing
  
Diarrhea
  
Extreme tiredness (fatigue)
  
Fever of 100.4°F or 38°C or greater
  
Headache
  
Loss of sense of taste and/or smell
  
Muscle Aches
  
Nausea/Vomiting
  
Shortness of Breath/Difficulty Breathing
  
Sore Throat
  

Fields marked with an asterisk (*) are required.