Millersville University Daily Health Questionnaire

Millersville University Daily Health Questionnaire
Name*

First NameLast Name
Risk
Email*
(This sends the results to your email, enabling documentation.)
Affiliation*
(Please identify whether you are a student, employee, or visitor)
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 had significant contact (defined as less than 6 feet for greater than 15 minutes) with anyone who has tested positive for COVID-19 in the past 14 days?*

YesNo
Have you tested positive for COVID-19 within the past 14 days?*

YesNo
Date

YearMonthDay
DateHourMinutesAM/PM Option
I certify all the information provided is shared to the best of my ability. If you replied YES to any of the above questions, please include your phone number below.
Phone Number
Should be Empty: