COVID-19 Daily Self Check List

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If you aren't able to use CoVerified to submit your required daily symptom report today, please use this COVID-19 Daily Self-Checklist instead. Complete and submit this form first thing each day until you can use CoVerified. If you are not willing or able to certify that you meet these health conditions, you may not be allowed into Simmons facilities.

If you are unable to answer yes to all questions, please DO NOT fill out this form and instead get in touch with the Simmons University Health Center as soon as possible at 617-521-1020. If it is beyond the Health Center's hours (Monday: 9 am - 6pm; Tuesday - Friday: 9 am - 5 pm), please call Public Safety to get in touch with the provider-on-call.

Email *

First Name *

Last Name *

Cell Phone Number *

The following symptoms can indicate possible COVID-19 infection:

- Fever (≥ 37.8°C/100°F)
- Sore throat (different from pre-existing allergies)
- Shortness of breath
- Difficulty breathing
- Unexplained muscle aches
- New onset cough
- Loss of sense of smell or taste
- Nasal congestion or runny nose (different from pre-existing allergies)
- New/unusual stomach issues

I am currently free of any from the aforementioned symptoms that can indicate possible COVID-19 infection: *

Yes

I have not been diagnosed with COVID-19 in the past 14 days. *

Yes

I do not live with someone who has been diagnosed with COVID-19. *

Yes

In the past 14 days, I have not been identified as a contact requiring self-monitoring for symptoms by a hospital, public health or government agency as part of “contact tracing” related to someone diagnosed with COVID-19. *

Yes

Neither I nor anyone I have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19. *

Yes

I have not been asked to self-isolate or quarantine by a medical professional or a local public health official. *

Yes

A copy of your responses will be emailed to the address you provided.

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