Maine Community College

Maine Community College

Daily Health Questionnaire
Name *

First (Given) Name Last Name (Surname)
Risk
Email *
(This sends the results to your email, enabling documentation.)
College *
Are you experiencing ONE OR MORE of the following COVID-19 related symptoms:
- Fever (100.4F or higher)
- Shortness of breath or difficulty breathing
- New cough
- New loss of taste or sense of smell
Are you experiencing ONE OR MORE of the following COVID-19 related symptoms: *

Yes No
Are you experiencing TWO OR MORE of the following COVID-19 related symptoms:
- Chills
- New headache
- New unexplained fatigue
- New onset of muscle or body aches
- Sore throat
- Congestion or runny nose, excluding known allergies
- Nausea or vomiting
- Diarrhea
Are you experiencing TWO OR MORE of the following COVID-19 related symptoms: *

Yes No
Did you test positive for COVID-19 and are currently required to isolate yourself from others? *

Yes No
In the past 14 days, have you been in close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with anyone known or suspected to have COVID-19? *

Yes No
In the past 10 days, did you attend an event or gathering or visit a crowded public place at which you and others present did not physically distance and wear a face covering? *

Yes No
In the past 10 days: 1) did you travel to a state other than New Hampshire, Vermont, Massachusetts, Connecticut, or Rhode Island AND 2) none of the following conditions apply to you:

a) You are not fully vaccinated (achieved 14 days after completion of your vaccination series);
b) You did not test positive, complete a 10 day isolation and fully recover from COVID 19 within the past 90 days;
c) You have not received a negative COVID-19 test result since your entry to Maine.
*

Yes No
Date

Year Month Day
Date Hour Minutes AM/PM Option
I certify all the information provided is shared to the best of my ability.
Should be Empty: