Fairfield University Daily Health Questionnaire

Instructions: Prior to arriving to campus each day, this health monitoring questionnaire must be completed by employees, students, and invited campus visitors. Completing the questionnaire is not a requirement on days employees or students are not physically present on campus.

Name *

First (Given) Name Last Name (Surname)

Risk

Email

(This sends the results to your email, enabling documentation.)

Affiliation *

Phone Number *

Area Code Phone Number

Who invited you? *

Are you experiencing any of the following symptoms? (symptoms not related to a diagnosed chronic condition)

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Are you experiencing any of the following symptoms? *

Yes No

In the past 14 days, have you been in close contact with an infectious individual diagnosed with COVID-19 or have you been advised to quarantine by a Public Health Official? Close contact is defined as within 6 feet for 15 minutes or longer. *

Yes No

Have you returned from international travel within the past 14 days? *

Yes No

Have you traveled to any of the states identified in Connecticut’s travel advisory?

https://portal.ct.gov/Coronavirus/Covid-19-Knowledge-Base/Travel-In-or-Out-of-CT (link is for reference to the states covered - please note that the link will remove you from the survey and delete your answers. We recommend copying the link and opening it in a browser separate of the survey and the LiveSafe App.)

Have you returned from a U.S. State on the CT Travel Advisory list within the past 14 days? *

Yes No

Employees: If you answer “yes” to any of the above questions: stay home and call your private Health Care Provider. Notify your supervisor you will be absent. If a Health Care Provider orders a COVID-19 diagnostic viral test and the results are pending or positive, notify your supervisor and Human Resources at 203-254-4000, Ext.4080. If you feel ill during the workday, go home, and follow the steps above. If you cannot go home immediately, a temporary isolation room will be arranged.

Students: If you answer “yes” to any of the above questions, isolate yourself in your Residence Hall room or home and call the Student Health Center at 203-254-4000, Ext. 2241 or call your private Health Care Provider. If a Health Care Provider orders a COVID-19 diagnostic viral test and the results are pending or positive, notify the Student Health Center.

Campus Visitors: If you answer “yes” to any of the above questions, stay home and contact your private Health Care Provider. If you answer “no” to the above questions, monitor for the identified symptoms. If symptoms develop within 48 hours of visiting campus, seek medical care. If a Health Care Provider orders a COVID-19 diagnostic viral test and the results are pending or positive, notify Fairfield University Public Safety at 203-254-4000, Ext. 4090.

Date

Date Hour Minutes AM/PM Option

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