Daily Student Self Monitoring Form

A form students fill out each day to declare their health status, review possible symptoms, and confirm they are safe to come to campus.

Use this template

Date

Name

First Name

Last Name

Student ID

Phone Number

Email

Your Department

Your Campus

Please review the following symptoms list before answering

Are you experiencing any of the symptoms listed above today or have you experienced any within the last 24 hours?

Yes No

In the past 24 hours have been confirmed as positive for having COVID-19?

Yes No

In the past 14 days have you had close contact with someone who is confirmed as having COVID-19?

Yes No

Have you traveled outside of the state in the past 14 days?

Yes No

Acknowledgement

No image

Certification Statement

No image

I, undersigned, agree with the following statements:

I confirm the information provided above is true and accurate

Signature

Sign here

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