Name *

First

Last

Email *

In the past 24 hours, have you exhibited any of the following symptoms of an unknown origin? *

No
Yes

• Fever of 100.4℉ or higher
• Cough
• Shortness of breath
• Conjunctivitis (red eyes)
• Loss of smell or taste
• Severe headache
• Sore throat
• Chills and/or body aches
• GI symptoms including vomiting, diarrhea, or nausea

Are you currently under self-isolation or quarantine as a directive by the local health department or your healthcare provider? *

No
Yes

Is your current body temperature 100.4℉ or higher? *

No
Yes

If you have questions or need assistance with the COVID-19 assessment process, please call Campus Patrol at (810) 989-5757.

COVID-19 Self-Assessment Form

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