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DAILY SELF HEALTH MONITORING FORM

SYMPTOMS – answer yes or no to each – every day

Yes
No
Do you have a fever?
(A fever is a temperature of 100.4° F [38.0° C] or greater using an oral thermometer)
 
 
Have you had any of these symptoms in the past 24 hours?
  • New cough
  • Sore throat
  • Shortness of breath or trouble breathing
  • Headache
  • New body aches or muscle pain
  • New loss of taste or smell
  • New fatigue
  • Nausea or vomiting
  • Diarrhea
 
 
Have you had any of these symptoms in the past 24 hours not related to allergies?
  • Runny nose
  • Stuffy nose
  • Sneezing
 
 
If you have had runny nose, stuffy nose, sneezing in the past 24 hours, is it getting worse?
 
 

EXPOSURES – check yes or no

Yes
No
Have you traveled outside the state (other than to your personal residence) in the past 14 days?
 
 
Have you been in close contact with someone with a confirmed or suspected case of COVID-19 in the past 14 days?
 
 
Have you been diagnosed with COVID-19?
 
 

 

If You Answered Yes to Any of the Above:

Students: Do not leave your room/come to campus, contact the Wellness Center at 724-946-7927 immediately for further instructions.

Employees & Visitors: Do not come to campus. Contact your healthcare provider for further instructions.

 

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