Daily Screening

The university continues to act in good faith to fulfill its obligation to protect members of the UofSC Aiken community from COVID-19 to the greatest extent possible. The information collected on this form will be used to help the university address your needs and prevent the spread of COVID-19. State and federal law and university policy prohibit discrimination based on age, disability, genetics, race, color, national origin, sex, gender, religion, sexual orientation, protected veteran status, pregnancy, childbirth or medical conditions related to pregnancy or childbirth.

If you believe you have been a victim of unlawful discrimination because of information you provided on this form, you may contact the UofSC Aiken Human Resources Office at 803-641-3317, or by email at HR@usca.edu.

Name*

First Name

Last Name

Today's Date*

Send Self-Assessment To*

Question 1: Have you been diagnosed with the Novel Coronavirus, COVID-19?

Yes No

Question 2: Have you traveled out of the country or to high risk areas in the last month?

Yes No

Question 3: In the last two weeks, have you visited, lived with, or been in close contact with someone for 15 minutes, consecutively or longer that has COVID-19?

Yes No

Question 4: Have you lived with or been in close contact for 15 minutes consecutively or longer with anyone who has been quarantined or isolated due to suspicion of COVID-19?

Yes No

Question 5: Are you newly experiencing any of the following symptoms?

Yes No

Fever (temp of 100.4° F or higher)	Cough	Shortness of Breath	Sore Throat	Abdominal Pain	Nausea	Fatigue
Headache	Muscle Aches	Diarrhea	Runny Nose	Vomiting	Chills / Shaking	Loss of Sense (smell / taste)

Newly meaning these are not symptoms you experience on a regular basis. The symptoms listed above are often associated with early onset of COVID-19:

Note: If you have answered “Yes” to any questions above, if your symptoms worsen, or if additional symptoms emerge, please either stay home or if you are already on campus, exit the building with your mask/face cover in place. Please contact your supervisor for further instructions and your health care provider when applicable.

Question 6: I certify that I am taking my temperature each day and I am keeping track of my temperature.

Yes No

Question 7: I certify that I will report any changes to my health related to the symptoms of COVID-19 to my supervisor and will remain at home if any symptoms emerge from my daily health screening.

Yes No