Health Questionnaire

Each time anybody enters the campus, they must have the Health Questionnaire filled out online (see below) within 24 hours prior to coming to campus or complete a hard copy to submit at check-in.

A .pdf of the questionnaire is available for emailing or printing.

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.