BTM COVID-19 Self Screening Questionnaire Jotform Final

Student's Name *

First Name Last Name

Date *

Date

If you answer “YES” to any of these questions below, please see specific instructions below each question to determine how to proceed.

1) Regardless of your vaccination status, have you had any of the following symptoms in the last 24 hours: *

	Yes	No
Fever (usually 100.4 or higher)
Vomiting

Regardless of your vaccination status, if you answered “Yes” to any part of question one, please DO NOT come to Bridge until you receive a negative COVID-19 test AND are symptom free for at least 24 hours.

2) ) Regardless of your vaccination status, have you had at least TWO of any of the following symptoms not attributable to another known cause in the last 24 hours: (at least one response required) *

	Yes	No
Shortness of breath or difficulty breathing
Repeated shaking with chills
Cough
Headache
Sore throat
New loss of taste or smell
Muscle Aches/Fatigue
Nausae/diarrhea
NO to ALL (select NO)

Regardless of your vaccination status, if you answered “Yes” to two or more parts of question two, please DO NOT come to Bridge until you receive a negative COVID-19 test.

3) In the last 10 days have you: *

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Tested positive for COVID-19?
Taken a COVID-19 test that you are awaiting results for?

Regardless of VACCINATION STATUS, if you answered “Yes” to any part of questions three, do not come to Bridge until you have isolated for 5 days OR received a negative COVID-19 test. For timing of testing, please follow the recommendation of your healthcare provider. Also, continue to monitor symptoms for 10 days and immediately isolate and get tested if you develop symtoms.

4) In the last 10 days, have you: *

	Yes	No
Attended a large gathering of more than 50 people where social distancing was not possible?
Travelled via commerical airline, public transportation, cruise ship, or any other method in close proximity with crowds?

Regardless of VACCINATION STATUS, if you answered “Yes” to any part of questions four, please follow the the recommendation of your healthcare provider regarding testing and/or isolation depending on the specific circumstances. Follow their recommendations or restrictions before returning to Bridge. Monitor symptoms for 10 days and immediately isolate and get tested if you develop symtoms.