University of La Verne Daily Health Questionnaire

University of La Verne Daily Health Questionnaire
Name (Nombre)*

First (Given) Name (Primer nombre)Last Name (Apellido)
Risk
Email*
Cell Phone (Numero de telefono)

Area CodePhone Number
Affiliation (Afiliación)*
Have you tested positive for COVID-19 in the last 10 days? (Ha dado positivo en COVID-19 en los últimos 10 días?)*

YesNo
Have you been in contact with anyone that was diagnosed with COVID-19 in the last 14 days? (Ha estado cerca de alguien que fue diagnosticado con COVID-19 en los últimos 14 días?)*

YesNo
Have you felt sick today? (Se ha sentido enfermo/a hoy)*

YesNo
COVID-19 Symptoms include (Sintomas de COVID-19 incluen):
- Fever or chills (Fiebre o escalofríos)
- Cough (Tos)
- Shortness of breath or difficulty breathing (Dificultad para respirar)
- Fatigue (Fatiga)
- Muscle or body aches (Dolores musculares o corporales)
- Headache (Dolor de cabeza)
- New loss of taste or smell (Nueva pérdida de sabor u olor)
- Sore throat (Dolor de garganta)
- Nasal congestion or runny nose (Congestión nasal o nariz con nequeo)
Are you experiencing any of the COVID-19 related symptoms noted above? (Tiene alguno de los síntomas mencionados?)*

YesNo
Date

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