Dons Health Check

These questions are being asked to help limit the spread of COVID-19. All responses will be kept confidential and will only be disclosed to the extent permitted by law.

First Name*

Last Name*

Email Address*

What date are you planning to visit campus?*

Will you have guests joining you for your campus visit?*

Yes

No

DeleteGuest _ID_
Please provide the first name, last name and email address for each guest that will be accompanying you on your visit to campus.
First Name Last Name Email Address

Add another guest

Please provide the first name, last name and email address for each guest that will be accompanying you on your visit to campus.

Within the last 10 days, have you or anyone in your party been diagnosed with COVID-19 or had a test confirming you have the virus?*

Yes

No

Have you or anyone in your party had close contact with a person who has been diagnosed with or is suspected of having COVID-19 within the past 10 days?*

Yes

No

Do you or anyone in your party have any of the following symptoms symptoms associated with COVID-19 that cannot otherwise be explained?*

Fever, Chills, or Repeated Shaking/Shivering
Cough
Sore Throat
Shortness of Breath, Difficulty Breathing
Feeling Unusually Weak or Fatigued
Loss of Taste or Smell
Muscle pain
Headache
Runny or congested nose
Diarrhea

Do you or anyone in your party have any of the following symptoms symptoms associated with COVID-19 that cannot otherwise be explained?*

Fever, Chills, or Repeated Shaking/Shivering
Cough
Sore Throat
Shortness of Breath, Difficulty Breathing
Feeling Unusually Weak or Fatigued
Loss of Taste or Smell
Muscle pain
Headache
Runny or congested nose
Diarrhea

Yes

No

I agree to abide by all policies and protocols set forth by the San Francisco Department of Public Health and the University of San Francisco.*

Dons Health Check

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