Pittsburgh Theological Seminary Daily Health Questionnaire

Pittsburgh Theological Seminary

Daily Health Questionnaire
Device Time

YearMonthDay
DateHourMinutesAM/PM Option
Name*

First (Given) NameLast Name (Surname)
Risk
Email*
(This sends the results to your email.)
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 COVID19 related symptoms noted above OR have tested positive in the past 5 days?*

YesNo
Have you been fully vaccinated against COVID19?*

YesNo
Have you been in close contact with someone who has tested positive for COVID-19 in the last 5 days?*

YesNo
Have you been tested for COVID-19 in the last seven days

YesNo
What were the results of the test?

Positive for COVID-19Negative for COVID-19
Are you living with or caring for an individual who is a suspected or confirmed case of COVID - 19?

YesNo
Have you been in contact with anyone known or suspected to have COVID - 19 in the last 14 days?

YesNo
Have you tested positive for COVID-19 in the last 14 days?

YesNo
What is the reason for your visit to the campus?*
What is the best phone number to reach you at?*
I certify all the information provided is shared to the best of my ability.
Should be Empty: