Fillable form to Julie MacTaggart, director of human resources, (University of Dubuque)

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form to Julie MacTaggart, director of human resources, (University of Dubuque)

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Please complete this form to assess your potential exposure/possession of COVID-19 and other illnesses. Please return completed
form to Julie MacTaggart, director of human resources, via email at Jmactaggart@dbq.edu.
Employee ID: ____________________ Employee Name: ___________________________________________________
Are you currently free from illness?
□ Yes □ No
Do you have a serious underlying medical condition?
□ Yes □ No
If
yes, please indicate: _____________________________________________________________________________
If the ser
ious underlying medical condition is among those considered by the US Centers for Disease Control and Prevention
as being at higher risk for COVID-19, do you request an accommodation?
□ Yes □ No If yes, please indicate the accommodation: _______________________________________
*The University will do its best to fulfil reasonable accommodation requests; however, it cannot guarantee all accommodation
requests will be fulfilled.
Are you curr
ently presenting with any of the following symptoms:
Have you be
en diagnosed with COVID-19 in the last six months?
□ Yes □ No
If yes, please indicate date of diagnosis: ____________________
If yes, please indicate date your medical provider said you could return to normal daily activities: ____________________
Have you r
ecently had any direct contact with a person who is presumed positive or confirmed positive of COVID-19?
□ Yes □ No If so, when? ___________________
Have you traveled internationally recently?
□ Yes □ No If yes, where? ____________________
Have you resided outside of Iowa the past month?
□ Yes □ No If yes, where? ____________________
Have you tr
aveled outside of your county of residence in the last 14 days?
□ Yes □ No
If yes, please indicate all
places traveled: ____________________________________________________________
Employee Signature: _____________________________________ Date: ____________________________________
Symptom
Yes
No
Fever (100.4 or higher)
□
□
Body Chills
□
□
Extreme Level of Fatigue
□
□
Cough
□
□
Pain/Difficulty Breathing
□
□
Shortness of Breath
□
□
Sore Throat
□
□
Body/Muscle Aches
□
□
Loss of Taste
□
□
Loss of Smell
□
□
Changes to Vision/Eye Discharge
□
□
Appendix 1 - Health Screening Survey
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Completed 29 August 2020

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