Waynesburg University COVID-19 Screening Form

Student forms will be forwarded to Jennifer Dean, Director of Student Health Services. Employee and visitor forms will be forwarded to Tom Helmick, Director of Human Resources

Name Name First Last
Date Date / MM / DD YYYY
Phone Phone - ### - ### ####
Email *
I am a(n): *

This information will be sent to Jennifer Dean, Director of Health Services, if student is selected.
Before you submit this form, please complete the initial screening by using the Apple Screening App or Google FormGoogle Form. This form should be completed if the daily screening has indicated that you have COVID-19 symptoms or possible exposure.
I have been instructed to complete this screening form by Health Services or Athletic Training. *
Department or Division
Please indicate below the Vice President or Supervisor who oversees your department: *

Vice President or Supervisor indicated will receive notification.
Can you effectively perform the work required for your role remotely (please discuss this with your supervisor)?
Date of Visit Date of Visit / MM / DD YYYY
Supervisor of Office Visited: *

Vice President or Supervisor indicated will receive notification.
Company or reason for visit
Individual you are visiting Individual you are visiting First Last
Residence *

Resident Director indicated will receive notification
Room Number
Are you a student athlete?
Student athlete forms will be forwarded to Andy Palko, Assistant Professor of Athletic Training Clinical Education Coordinator *
Sport

Sport Baseball Men’s Basketball Women’s Basketball Men’s Cross Country Women’s Cross Country Football Men’s Golf Women’s Golf Lacrosse Men’s Soccer Women’s Soccer Softball Men’s Tennis Women’s Tennis Men’s Indoor Track & Field Women’s Indoor Track & Field Men’s Outdoor Track & Field Women’s Outdoor Track & Field Volleyball Wrestling
Have you or anyone you have been in close contact (6 feet or less with or without masks for a cumulative total of 10-15 minutes or more) within the last 14 days tested positive for COVID-19?
Please explain
Are you experiencing now or have you experienced the following symptoms in the last 14 days: fever, cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, new loss of taste or smell, headache, nausea, diarrhea and/or new GI symptoms?
Check all that apply

Check all that apply Fever Cough Shortness of breath or difficulty breathing Chills Muscle pain Sore throat New loss of taste or smell Headache Nausea Diarrhea New GI symptoms
Have you been in close contact (6 feet or less with or without masks for a cumulative total of 10-15 minutes or more) with anyone experiencing the following symptoms now or within the last 14 days: fever, cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, new loss of taste or smell, headache, nausea, diarrhea and/or new GI symptoms?
Do you need personal protective equipment (mask, gloves, etc.) provided for your use when you are on campus property?
Please explain
Have you traveled to a location designated as a COVID-19 'hot spot" or "red area" within the past 14 days? (Click here to to access current "hot spots" as identified by the Dept. of Health)
Please explain