Covid-19 Self-Report Illness FormPlease answer the following health questions as part of WPCC’s screening for COVID-19.Date Date Format: MM slash DD slash YYYY Name First Last Student ID NumberTelephone NumberReporting ExposureHave you had close contact (less than 6 feet for more than 10 minutes) in the last 14 days with someone diagnosed with COVID-19. and has any health department or health care provider been in contact with you and advised you to quarantine?YesNoDate of Symptoms OnsetWhen did the person you had close contact with start showing symptoms? Date Format: MM slash DD slash YYYY Date of Last ContactWhen was the last contact you had with this person? Date Format: MM slash DD slash YYYY Contact with Someone Tested for COVID-19*Have you had close contact (less than 6 feet for more than 10 minutes) in the last 4 to 7 days with someone who has been tested for COVID-19?YesNoDate of Synptoms OnsetWhen did the person you had close contact with start showing symptoms? Date Format: MM slash DD slash YYYY Date of Last ContactWhen was the last contact you had with this person? Date Format: MM slash DD slash YYYY SymptomsSince you were last at school, have you had any of these symptoms? (Check all that apply) I Have Not Experienced Any Synptoms Fever Chills Shortness of Breath New Cough Sore Throat New Loss of Taste or Smell Nausea/Vomiting Diarrhea Headache Muscle Pain Fatigue Congestion Runny NoseWhen did your symptoms start? Date Format: MM slash DD slash YYYY Tested for COVID-19Since you were last at school, have you been diagnosed with COVID-19?YesNoDate Tested Date Format: MM slash DD slash YYYY ResultLast Date You Were On Campus: Date Format: MM slash DD slash YYYY
