Fillable Northeastern University Self-Monitoring Form (COVID-19)

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Northeastern University Self-Monitoring Form (COVID-19)

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Coronavirus Disease 2019 (COVID-19)
Self- Monitoring Instructions
Northeastern University recommends that faculty, staff, and students who have
traveled to Level 3 countries monitor their health for 14 days while remaining at
home, avoiding visitors, and not attending classes or other group gatherings.
For information about Level 3 countries, please go to CDC Warning – Level 3
country. Northeastern affiliates who have traveled to a CDC Alert – Level 2 country
within the previous fourteen (14) days are also encouraged to monitor their health.
The following pages provide information about how to monitor for COVID-19. The
self-monitoring form can be completed over fourteen days. Each day, a person
should complete the form two times, monitoring for specific symptoms of COVID-19
(fever, difficulty breathing and cough). Please record your temperature twice daily
along with indicating if other symptoms have been present.
Fever
Cough
Difficulty Breathing
Report any temperature above 100.4 F / 38.0 C or persistent symptoms immediately
to your local healthcare service or practitioner!
Monitor for Symptoms for 14 days after exposure:
Contact Information:
Boston:
NUPD - 617.373.2121
UHCS - 617.373.2772
Bay Area:
San Francisco - 415.554.2955
San Jose - 408.792.5007
866.462.3821
Washington:
800.525.0127.
Individuals can also contact their General Practitioner/healthcare provider
Completed forms can be emailed to oem@northeastern.e
du
Canada:
833.784.4397
England:
Local Healthcare - 999 / 111
Adapted from Public Health Ontario
Updated Last on 3/6/2020
Infectious Disease –
Coronavirus Symptom Self-Monitoring Form
Name:
NU ID #:
Date of Birth:
Year:
Telephone #:
Program:
Email:
Local Address:
Date
Temperature
(Twice Daily)
Difficulty
Breathing
Cough
Comments
(X) (X) (X)
Signature: __________________________________________________ Date:______________________
Please send completed form to Northeastern Emergency Management at oem@northeastern.edu
Please complete each line of the symptom columns, twice
daily until the self-monitoring end date is reached. Per CDC
guidelines, temperature must be measured twice a day.
Report any temperature above 100.4 F / 38.0 C or persistent
symptoms immediately to your local healthcare service
listed to the right.
Boston: NUPD at 617.373.2121 / UHCS at
617.373.2772
Bay Area: 415.554.2955 (San Fransisco)
408.792.5007 (San Jose)
Canada: 833.784.4397
England: Local Healthcare 999 / 111
North Carolina: 866.462.3821
Washington: 800.525.0127
STUDENT / STAFF DETAILS
Adapted from CDC and UC San Francisco
Last Revised 3/6/2020
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Northeastern University Self-Monitoring Form (COVID-19)

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Completed 29 March 2020

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