CDC Mandatory Health Questionnaire

CDC Mandatory Health Questionnaire
Are you a Staff, Student or Visitor? *
Are you working Virtually (Working from Home)? *
Campus Location *
Date of Entry to Location *

Month Day Year
Date
Please read the following statements and select your response from the drop down below.
- Do you have a fever? ¿Tienes fiebre?
- Do you have any respiratory symptoms? (coughing, sneezing, difficulty breathing?) ¿Tienes síntomas respiratorio?
- Have you traveled out of the country or visited a state on the travel advisory list in the last 14 days? (not including NY and PA) ¿Ha viajado fuera del país o ha visitado un estado en la lista de avisos de viaje en los últimos 14 días?
  - Click here to view states on the travel advisory list.
Response *
Your selection from the drop down above will automatically answer the three questions to complete the form.
Do you have a fever? *
¿Tienes fiebre?
Do you have any respiratory symptoms? (coughing, sneezing, difficulty breathing?) *
¿Tienes síntomas respiratorio?
Have you traveled out of the country or visited a state on the travel advisory list in the last 14 days? (not including NY and PA) *
¿Ha viajado fuera del país o ha visitado un estado en la lista de avisos de viaje en los últimos 14 días?
The school nurse will receive an email for further evaluation if response of “Yes” to any of these questions are selected.
Full Name *

First Name Last Name
Email *
Please use your HCST email address if applicable.
Please make sure you also check your Spam or Junk mail for confirmation after submission.
Time

: Hour Minutes AM/PM Option

Office Use Only
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