Please complete all questions.

YOUR ID is the last four digits of your SSN and last 2 digits of your birth year. EXAMPLE: SSN: 123-45-6789 DOB 01/01/1980 Personal ID = 678980
Name*

Unrelated to a known medical condition, do you have any of the following symptoms?


Do you have one (or more) of the following symptoms?*
  • Fever >100
  • Nausea/Vomiting or Diarrhea
  • New loss of taste or smell
Do you have (3) three (or more) of the following symptoms?*
  • Chills
  • Cough
  • Headache
  • Runny Nose
  • Shortness of Breath that is new or worsening
  • Sore Throat
  • Unexplained Fatigue
  • Unexplained Muscle Aches
Have you or anyone in your household been diagnosed with COVID-19 in the past 14 days?*

If you answered YES to any of the questions, contact Employee Health at 238-2348.

New loss of taste or smell?
Chills?
Shortness of Breath that is new or worsening?
Cough?
Runny Nose?
Sore Throat?
Headache?
Unexplained Muscle Aches?
Unexplained Fatigue?
Have you traveled internationally or on a cruise ship in the past 14 days?
Have you or anyone in your household been diagnosed with COVID-19 in the past 14 days?
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