Bloomfield College Daily Health Questionnaire

Bloomfield College

Daily Health Questionnaire
Name*

First (Given) NameLast Name (Surname)
Risk
Email*
(This sends the results to your email, enabling documentation.)
Affiliation*
According to the U.S. Centers for Disease Control and Prevention & the World Health Organization, COVID-19 Symptoms include:
- 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 COVID-19 related symptoms noted above?*

YesNo
Are you living with or caring for an individual who is a suspected or confirmed case of COVID - 19?*

YesNo
Have you been in contact with anyone known or suspected to have COVID - 19 in the last 5 days?*

YesNo
Have you tested positive for COVID-19 in the past 5 days?*

YesNo
Date

YearMonthDay
DateHourMinutesAM/PM Option
I certify all the information provided is shared to the best of my ability.
Should be Empty: