COVID-19 STUDENT Self-Screening Tool
1. To be completed daily, prior to any on-campus activity

COVID-19 STUDENT Self-Screening Tool

To be completed daily, prior to any on-campus activity

Name: ___________________________________________________________

Contact Number: ___________________________________

Date: __________________ Site/Building_______________________

1.   Temperature taken at point of entry: ______________________

2. Do you have a cough?             Yes No

3. Are you Short of Breath?             Yes No

If yes:
When? ____________________________________________

Have you been in contact with a healthcare provider? Yes No

4. Have you traveled in the past 14 days? Yes No

If yes:

Where? __________________________________________________
When? ________________________________________________________

5. Have you been in contact with anyone who has been diagnosed with
COVID-19? Yes No

If yes, when: _________________________________________________

6. Have you been in contact with anyone that has had a cough, shortness of Breath or a fever in the past 14 days? Yes No

If Yes, when: _________________________________________________________________

You are consenting to a temperature scan, and you are affirming and attesting that the answers provided above are true and accurate. In the event you begin to feel sick on campus with any of the noted symptoms, you agree to notify the appropriate authority immediately. Students should notify their instructor and Dean’s office.

Although Delgado Community College is taking appropriate and significant precautions to ensure and maintain a safe and sanitary environment, you are ultimately responsible for following the safety guidelines provided to you (i.e., protective equipment, safe distancing, hand washing, etc.).

Student Signature:

Revised 5/28/2020