Daily Student Self Monitoring Form

Date

Name

First NameLast Name

Student ID

Number

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Your Department

Your Campus

Symptoms:

Are you experiencing any of the symptoms listed above today or have you experienced any within the last 24 hours?

In the past 24 hours have been confirmed as positive for having COVID-19?

In the past 14 days have you had close contact with someone who is confirmed as having COVID-19?

Have you traveled outside of the state in the past 14 days?

You can come to the campus.

Please STAY HOME & Contact your counselor for any questions. You can find remote service instructions on the College website: www.example.com

I, undersigned, agree with the following statements:

Signature