COVID Screening Form
Please provide as much information as possible. A SHAC clinician will review your submission and contact you for further assessment and if necessary, to establish a quarantine/isolation management plan.

A clinician from Student Health will contact you for further assessment and to establish a quarantine/isolation management plan. For forms submitted during normal business hours (Monday- Friday, 9:00am-3:00pm), a clinician will reach out within 24 hours. For forms submitted outside of normal business hours, including the weekend, we will do our best to address your concerns in a timely fashion.

Students who have had close contact with an individual with a known positive COVID diagnosis, or who are experiencing symptoms of COVID-19 (listed above), are not permitted to attend class on campus or attend clinical experiential learning rotations but may attend class via distance learning if able.

If you develop or experience any of the following symptoms, seek emergency medical care immediately:

- trouble breathing
- persistent pain or pressure in the chest
- new confusion
- inability to stay awake
- bluish lips or face

Call 911 or call ahead to your local emergency facility and to inform the operator that you are seeking care for someone who has or may have COVID-19.

A note about confidentiality:

Please be advised that any communication with students and close contacts will be carried out in a manner that preserves the confidentiality and privacy of all involved. This includes not revealing the name of a student to a close contact unless permission has been given, and not giving confidential information to third parties (e.g., roommates, neighbors, family members).



*** BE SURE TO HIT SUBMIT AT THE END OF THIS FORM ***
  • Demographic Information

  • - -
  • Leave blank if you live off-campus.
  • Leave blank if you live off-campus.
  • Private Shared
    Bedroom Type
    Bathroom Type
  • UNIVERSITY EMPLOYEES

    Please complete if you are a University employee.
  • SYMPTOMS & TESTING INFORMATION

  • This measure is without having taken any fever reducing medications.
  • / /
  • / /
  • / /
  • / /
  • If yes, please provide the vaccine information below.
  • Pfizer or Moderna
    Date of Dose 1
    Date of Dose 2
  • Please upload any relevant documents (i.e. lab results, medical provider notes, ER discharge instructions, etc.) here.
  • CLOSE CONTACTS

    DEFINITION OF CLOSE CONTACT: Someone who was within 6 feet (with or without a mask) of an infected person for a cumulative total of 15 minutes or more over a 24-hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.
  • Symptomatic Close Contacts

  • If yes, provide details below.
  • Name Phone Number Date/Time of Last Contact
    Contact 1
    Contact 2
    Contact 3
  • Diagnosed/Quarantined Close Contacts

  • If yes, provide details below.
  • Name Phone Number Date/Time of Last Contact Date of Diagnosis or Quarantine
    Contact 1
    Contact 2
    Contact 3
  • Other Contacts

    List the names and contact numbers of any USciences students, faculty or staff whom you have been in contact with this past week or whom you live with (housemates, roommates, teammates etc):
  • Name Phone Number Date/Time of Last Contact
    Contact 1
    Contact 2
    Contact 3
    Contact 4
    Contact 5
    Contact 6
    Contact 7
  • *** BE SURE TO CLICK THE ORANGE SUBMIT BUTTON BELOW ***