University of La Verne Daily Health Questionnaire

Instructions: Prior to arriving to campus each day, this health monitoring questionnaire must be completed by employees, students, university vendors and invited campus visitors (Antes de llegar a la Universidad todo empleado, estudiante y proveedor tiene que responder at estas preguntas)

Name (Nombre) *

First (Given) Name (Primer nombre) Last Name (Apellido)

Risk

Email *

(This sends the results to your email, enabling documentation / Esto envía los resultados a su correo electrónico, habilitando la documentación)

Cell Phone (Numero de telefono)

Area Code Phone 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?) *

Yes No

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

Yes No

Have you been instructed by a medical provider, public health professional, or University personnel that you need to quarantine or isolate in the last 14 days? (Ha sido referido por un médico, profesional de salud pública o personal de la Universidad que necesita ponerse en cuarentena o aislarse en los últimos 14 días?) *

Yes No

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

Yes No

Is your current oral or forehead temperature 99.9 ̊F or higher? (Ha tenido tempertura de 99.9 ̊F o mas alta?) *

Yes No

According to the U.S. Centers for Disease Control and Prevention & the World Health Organization, 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?) *

Yes No

Have you traveled outside of the State of CA in the last 10 days? (Ha viajado fuera del estado de CA en los últimos 10 días?) *

Yes No

Have you been on an ULV campus in the last 14 days? * (Has visitado un campus de ULV en los últimos 14 días?) *

Yes No

Date

Date Hour Minutes AM/PM Option

I certify all the information provided is shared to the best of my ability.