Please fill out and submit this document prior to arriving on campus. This screening will help us identify any concerns you may have about COVID-19. If you answer YES to any of these questions, please contact TSCT’s Health Office by email and 717-299-7769.
Name*
TSCT Email*
Phone*( ) -
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
In the last 14 days, have you been in close contact with anyone diagnosed with COVID-19?* Yes No
In the last 14 days have you been tested for COVID-19?* Yes No
If yes, what was your test result positive? * Yes No
Did you travel out of Pennsylvania in the last 2 weeks?* Yes No
If yes, where?
Do you have any concerns about your risk for COVID, such as pre-existing health concerns?* Yes No
If yes, please explain. Our Student Health Services nurse will follow up with you to discuss your concerns.
Fever symptoms: chills, sweats, feverish feeling (muscle or body aches) or a temperature of 100.4 F or higher
Dry, persistent cough
Shortness of breath (during rest)
Sore throat
New loss of taste and/or smell
Nausea, vomiting, or diarrhea
Fatigue
Congestion or runny nose
Headache
None of the above
