COVID-19 Assessment
COVID-19 Assessment
Date (Hidden Field)
Date (Hidden Field)
/
MM
/
DD
YYYY
CBU Affiliation
*
CBU Affiliation
Student
Employee
Visitor
Aramark
Resident or Commuter
*
Resident or Commuter
Resident
Commuter
Name
Name
*
First
Last
Email (CBU Email if Student or Employee)
*
1) Have you been in close contact with a confirmed case of COVID-19 in the last 14 days?
*
1) Have you been in close contact with a confirmed case of COVID-19 in the last 14 days?
Yes
No
2) Are you experiencing a cough, chills, shortness of breath, sore throat or muscle aches unrelated to previous chronic medical issues?
*
2) Are you experiencing a cough, chills, shortness of breath, sore throat or muscle aches unrelated to previous chronic medical issues?
Yes
No
3) Do you have a fever or have had a fever in the last 48 hours?
*
3) Do you have a fever or have had a fever in the last 48 hours?
Yes
No
4) Have you had a new loss of taste or smell?
*
4) Have you had a new loss of taste or smell?
Yes
No
5) Have you had any vomiting or diarrhea in the last 24 hours unrelated to previous chronic medical issues?
*
5) Have you had any vomiting or diarrhea in the last 24 hours unrelated to previous chronic medical issues?
Yes
No
6) Have you been asked to self-isolate or quarantine by a medical professional?
*
6) Have you been asked to self-isolate or quarantine by a medical professional?
Yes
No