HvZ: SFSU Covid-19 Screening Checklist

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For the safety of all attendees, all visitors are required to complete a COVID-19 screening before participating in our events.

Email *

Last Name, First Name *

Have you or someone with whom you have been in close proximity traveled to an outbreak area within the past 14 days? And/ or have you been in close contact with anyone who has been diagnosed as infected with, or is being tested for, COVID-19? If you answer "Yes", we ask that you stop working on the survey, as well as to not attend this event. Please self-quarantine for 14 days.
*

Yes

Have you tested positive for COVID-19 or been diagnosed as COVID-19 positive by a healthcare provider within the last 10 days? If you answer "Yes", we ask that you stop working on the survey, as well as to not attend this event. Please self-quarantine for 14 days.
*

Yes

Within the last 24 hours, have you experienced any of the following symptoms that cannot be attributed to another health condition? If you checked any of the boxes aside from "*NONE OF THE ABOVE*", we ask that you stop working on the survey, as well as to not attend this event. Please self-quarantine for 14 days.
*

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

Loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

*NONE OF THE ABOVE*

Required

I hereby certify that I have read and understood all the statements and questions in the questionnaire. And that my responses provided are true and accurate to the best of my knowledge.
*

I acknowledge

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