Health Questionnaire

COVID-19 Health Questionnaire

This Health Questionnaire must be filled out by any students, staff, faculty, and visitors within 24 hours prior to coming to campus.

If you see this don't fill out this input box.

First Name *

Last Name *

Date and Time *

Phone *

In the past 14 days have you tested positive for the virus, and/or had close contact with a confirmed or suspected case of COVID-19? *

Yes

In the past 14 days, have you traveled to any of the restricted/advisory States as listed by governor's office? *

Yes

Have you experienced any of the following symptoms: Cough, shortness of breath, or difficulty breathing? *

Yes

Have you experienced at least two of the following symptoms: fever of 100.4 F or higher, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste and/or smell? *

Yes

What's your temperature today? (please enter in degrees Fahrenheit, e.g. 98.6) *

By submitting this information you confirm that the information below is an accurate record of your body temperature(s) during the two weeks preceding your return to Clinton Community College.