COVID-19 Pre-Screening

To protect the health of the Ouachita community, all campus visitors are required to complete the following prior to visiting campus. Additionally, faculty, staff and students who have traveled outside of the United States must complete the form before returning to campus. (For groups/families, these questions apply to everyone in your party, so if any member can answer “Yes,” then you must record a “Yes” for the group.)

Visitor Information

I am a...

Employee

Current Student-Athlete

Current Student

Guest

Who and/or for what purpose are you visiting?

First Name

Last Name

Email Address

Cell Phone Number

Screening Questions

Have you traveled outside of the Unites States in the past month?

Where?

Please describe the places in which you were in contact with people. (Examples: I stayed with family in the house all day, I went shopping to the mall, I played tennis outside, etc.)

In the past 14 days, have you been in contact with a person who was infected with the novel coronavirus (COVID-19) at the time of your contact with them?

Please describe the nature of the contact. (Examples: I stayed in the house with them, I saw them in the car but never was closer than 6 feet, I went to a location and later found out a person there was infected, etc.)

In the past few days, have you had the following symptoms: felt unwell, especially with respiratory symptoms (cough, fever, shortness of breath, or difficulty breathing)? Experienced fatigue, diarrhea, sore throat, or loss of smell/taste?

Please describe if you have been to a physician/provider, if you’ve been tested for COVID-19 (and if positive), and any details of the symptoms.

With HIPAA regulations, you are not required to give personal health information unless you choose to do so. If you prefer to only answer “YES,” then you will need to go to a screening/testing location for an evaluation before coming to campus.

Signature

Date