Health Screening Form - Els for Autism

Email*

Name*

First Last

Company Name

Date Entering Campus*

Time*

: HH

MM

Are you currently awaiting results for a COVID-19 test?*

Are you experiencing any of the following symptoms?*

If so, check the symptom below.

Fever
Shortness of breath
Dry Cough
Runny Nose
Sore Throat
Sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies
Headaches, fatigue, or weaknesses
Lost sense of taste and/or smell
No Symptoms

Within the last 10 days, have you traveled to any foreign country?*

Within the last 3 days, have you traveled within the United States?*

Where have you traveled to?*