California Institute of the Arts Daily Health Questionnaire

California Institute of the Arts

Daily Health Questionnaire
Name*

First (Given) NameLast Name (Surname)
Risk
Email
(This sends the results to your email, enabling documentation.)
According to the U.S. Centers for Disease Control and Prevention & the World Health Organization, COVID-19 Symptoms include:
- Fever (at or over 100.4f)
- Chills
- Cough
- Shortness of breath or difficulty breathing
- Fatigue
- 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
Have you been in contact with anyone known to have COVID 19 in the last 10 days?*

YesNo
Are you fully vaccinated?

YesNo
Have you tested positive for COVID-19 in the last 10 days?*

YesNo
Date

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