UWL-LCHD Active Monitoring Form
UW-L and the La Crosse County Health Department seeks to actively monitor and ensure the safety and security of students living in La Crosse County. Towards this goal, we are requesting that each student *who will remain living OR working in La Crosse* complete this form.

WHAT WE WILL DO: UW-L and the Health Department will jointly review all responses. Anyone who needs to be contacted based on responses may receive email or phone communication from either place.

PLEASE NOTE: If you have or develop any of the following symptoms at anytime, please notify UW-L Health. Symptoms of COVID-19 include: cough, fever (in this case, 100.0 or greater) and chills, abnormal tiredness, muscle aches, sore throat, shortness of breath or chest tightness, and rarely, upset stomach.
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What is your name? *
What is your phone number? *
Are you planning on spending time overnight in La Crosse County during the months of March or April, 2020? *
When you are staying in La Crosse County, do you stay on campus or off campus? *
ON CAMPUS: Which resident hall do you live in?
Clear selection
OFF CAMPUS: Which city do you live in?
Clear selection
To what cities, states, or countries outside of La Cross County, Wisconsin did you travel to in the past 14 days? Please include any airports you traveled through. *
Do you currently have any of the following symptoms? SELECT ALL THAT APPLY. *
Required
IF YES: When did your symptoms start?
In the past 14 days, have you been in direct contact with someone who was diagnosed with COVID-19?
Clear selection
If there is any other information you would like us to be aware of, please share that information here.
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