Student Self Check
Student First Name
*
Student Last Name
*
Campus
*
Claremont
Upland
Date
*
-
Month
-
Day
Year
Date
Has the student or anyone in their household been diagnosed with COVID-19, or been in close contact (closer than 6ft for more than 15 min over a 24 hour period) with someone diagnosed with COVID-19 within the last 14 days?
*
Yes
No
Please check any symptoms the student or anyone in their household is currently experiencing. Leave blank if none.
Fever, Chills, Headache, Fatigue, Muscle or Body Aches
Cough, Sore Throat, Congestion, or Runny Nose
Shortness of Breath or Difficulty Breathing
New Loss of Taste or Smell
Vomiting, Diarrhea, or Nausea
Are the symptoms checked above related to a known condition or confirmed diagnosis other than COVID-19?
*
Yes
No
Has the student or anyone in their household had any of the above symptoms in the past 10 days?
*
Yes
No
Were the symptoms related to a known condition or confirmed diagnosis other than COVID-19, OR, has the student since received medical clearance or a negative COVID-19 test with no fever for 24 hours (without the use of fever reducing medicine), AND the student has felt well for 24 hour?
Yes
No
Signee Name
*
Signature
*
Submit
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