Fillable COVID-19 Screening and Reporting Tool - Visitor or (University of Oklahoma)

Fill Online, Printable, Fillable, Blank COVID-19 Screening and Reporting Tool - Visitor or (University of Oklahoma) Form

Use Fill to complete blank online UNIVERSITY OF OKLAHOMA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

COVID-19 Screening and Reporting Tool - Visitor or (University of Oklahoma)

On average this form takes 21 minutes to complete

The COVID-19 Screening and Reporting Tool - Visitor or (University of Oklahoma) form is 4 pages long and contains:

  • 1 signature
  • 1 check-box
  • 80 other fields

Country of origin: US
File type: PDF

U.S.A. forms for University of Oklahoma

BROWSE UNIVERSITY OF OKLAHOMA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
COVID-19 Screening and Reporting Tool - Visitor or Vendor
Visitor Information
Travel History
First Name * Last Name *
Email * Date of Birth *
!
Phone Number *
Phone Number of Contact Person
Visitor Hosting Information
Contact Person at OU
Job Title
Department/College
Building You are Visiting
Specific Campus You are Visiting (OKC, Tulsa, Norman, Other)
Expected date of campus visit
!
Have you traveled or resided outside of Oklahoma within the last 14 days? *
Yes No
Date you left your primary/previous residence *
!
Date you returned to/arrived in Oklahoma *
!
List all states traveled * List all countries traveled *
List all cities traveled * List all modes of travel *
Reason for Campus Visit
Were you wearing a mask at all times while traveling*
Yes No
Event Attendance
Symptom Information
Have you spent time on a cruise ship within the last 14 days? *
Yes No
Additional comments regarding travel:
Have you attended an event/entertainment venue/gathering or group of greater than 10 people within the last 14 days? The people in your
household do not count towards the 10 people. *
Yes No
Event/Entertainment Venue/Gathering or Group setting *
Attendance start date *
!
Attendance end date *
!
Did you wear a mask at all times during the event/entertainment
venue/gathering or group? *
Yes No
Have you experienced any symptoms within the last 14 days? *
Yes No
Experiencing chills? *
Yes No
Experiencing cough? *
Yes No
Experiencing fever? *
Yes No
Experiencing loss of taste or smell? *
Yes No
Were all other participants wearing a mask at all times during the event/entertainment
venue/gathering or group? *
Did you maintain appropriate social distancing at all times? *
Yes No
Yes
No
Exposure Information
Testing Information
Experiencing muscle pain? *
Yes No
Experiencing shortness of breath? *
Yes No
Experiencing sore throat? *
Yes No
Experiencing other symptoms?
Date of Onset of First Symptom *
!
Have all of your symptoms resolved? *
Yes No
Have you had direct contact with Confirmed (+) COVID-19 within the last 14 days? *
Yes No
Have you had direct contact to someone awaiting COVID-19 test results within the last 14 days? *
Yes No
Have you had direct contact with a person experiencing symptoms of concern for COVID-19 within the last 14 days? *
Yes No
Do you share a household with anyone who has had symptoms within the last 14 days? *
Yes No
Do you share a household with anyone who has been instructed to Self-Isolate within the last 14 days? *
Yes No
Do you share a household with anyone who has been diagnosed with COVID-19 within the last 90 days? *
Yes No
Have you been tested for COVID-19 within the last 60 days? *
Yes No
Have you had a positive PCR test for COVID-19 within the last 60 days? *
Yes No
Date of Exposure(s):
!
Additional Comments
Most Recent test date:
!
List test result: Pending; Negative; Positive
Most recent test type: Nasopharyngeal (NP) swab-PCR or Other
Please specify what Other test you had:
The information submitted on this form is complete and accurate to the best of my knowledge.
I acknowledge that this screening tool is being used for clearance to visit campus for the specified reasons and dates stated within this form, based on
information I provided. It is not intended for use regarding personal medical evaluation, advice, decisions, and/or treatment. Seek care from your
primary care provider or emergency services, as appropriate, for any personal medical needs. I understand this information is being collected for the
purpose of infection prevention and public/employee safety.
I Agree
_____________________________________________________ Date: ______________________
Please sign, date, and email this form to the appropriate OU campus Employee Health Office as listed below.
A medical professional will be in contact with you, typically within 24 hours following submission of your form.
Copyright © 2020 The Board of Regents of the University of Oklahoma. All rights reserved.
Disclaimer | Copyright | The University of Oklahoma is an Equal Opportunity Employer | Mission Statement
Call 405.271.9675
Call 918.660.3102
Call 405.325.8732
Questions?
Questions?
Questions?
OUHSC OKC:
OUHSC Tulsa:
OU Norman:
Email to: EmployeeStudentHealth@ouhsc.edu
Email to: TulsaStudentHealth@ouhsc.edu
Email to: covidscreening@ou.edu
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

COVID-19 Screening and Reporting Tool - Visitor or (University of Oklahoma)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document