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 5 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 AND you are unvaccinated OR had your second Moderna vaccination more than 6 months ago or your second Pfizer vaccination more than 5 months ago or your Johnson and Johnson vaccination more than 2 months ago, AND you have not received a booster shot? *

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
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: