COVID-19 Questionnaire
Spring 2021
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First Name *
Last Name *
Email
Class Cohort *
Today's Date *
MM
/
DD
/
YYYY
In the past 14 days, have you tested positive for COVID-19? *
In the past 24 hours have you experienced any of the following symptoms? *
Fever of 100.4 degrees Fahrenheit, chills, cough, shortness of breath or difficulty breathing, muscle pain, headache, sore throat, nasal congestion, loss of taste/smell, diarrhea, nausea/vomiting
If you answered YES to the previous question list the symptoms exhibited:
In the past 14 days, have you been in close contact (less than 6 feet for more than 10 minutes) with anyone who has exhibited any of the symptoms below or has tested positive for COVID-19? *
Fever of 100.4 degrees Fahrenheit, chills, cough, shortness of breath or difficulty breathing, muscle pain, headache, sore throat, nasal congestion, loss of taste/smell, diarrhea, nausea/vomiting
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