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MCM Daily COVID-19 Sympton Self-Screen
This online form should be completed by staff and students prior to coming to MCM.
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The purpose of the COVID-19 Symptom Self Screen is to help you make decisions regarding the safety of going to work or class. This is not intended for the diagnosis or treatment of disease or other conditions, including COVID-19. By completing this form you acknowledge that the information provided may be used to assist in contact tracing for the MCM community. *
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First Name
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Your answer
Last Name
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Your answer
Preferred phone contact.
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Have you had any of the following symptoms since your last day at work or the last time you were here that you cannot attribute to another health condition?
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Fever or feeling feverish?
Chills?
A new cough?
Shortness of breath?
A new sore throat?
New muscle aches?
New headache?
New loss of taste or smell?
NO. NONE OF THE ABOVE
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If you answered “Yes” to any of the screening questions, you should stay home, stay away from other people, and contact your health care provider.
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