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.
_____________________________________________________ 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.
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Email to: EmployeeStudentHealth@ouhsc.edu
Email to: TulsaStudentHealth@ouhsc.edu
Email to: email@example.com
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