ORU Wellness Check

1
Name* This field is required.
2
Email* This field is required.
example@example.com
3
Personnel Status* This field is required.
Faculty
Staff
Student
Guest
Contractor
4
Date* This field is required.Please verify date before moving
Date
Month
Day
Year
08
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Hour
50
00
10
20
30
40
50
Minutes
5
Q1 - Are you experiencing symptoms consistent with COVID-19 including fever of 100.4 degrees or higher or chills, persistent cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, nausea or vomiting, diarrhea, or loss of taste/smell?* This field is required.
YESNO
6
Q2 - Without social distancing or wearing a mask, have you been within six feet of a sick person with COVID-19 for 15 minutes or more in the past 14 days and/or are you actively caring for a person sick with COVID-19?* This field is required.
YESNO
7
Q3 - Do you have a mask or scarf to wear in public places when social distancing isn't possible?* This field is required.
YESNO
8
Score
Pass
Fail
9
Image Field
Should be Empty: