NDS Faculty and Staff Health Check Survey

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Select Your Name *

Date *

YYYY

Temperature reading upon entry to building? *

Do you have a cough, runny nose, sore throat, or shortness of breath? *

Yes

Do you have any flu-like symptoms (fatigue, chills, muscle aches) *

Yes

Have you had gastrointestinal issues (nausea, vomiting, or diarrhea) within the last 24 hours? * *

Yes

Have you taken any symptom relieving medication? (Tylenol, Ibuprofen, cough medicine, Lozenges, any allergy medication) in the last 24 hours? *

Yes

Do you have a doctor's note or other proof that these symptoms are a result of allergies or other non-communicable ailments? *

Yes

Has anyone in your immediate family/household been diagnosed with COVID-19? *

Yes

Have you traveled outside of our state or country in the last 14 days? *

Yes

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