Skip to Navigation Screening for Possible Novel Coronavirus COVID-19 Step 1 of 3 33% Please read before starting This form should not be completed by Dominican College students. If you are a Dominican College student, the correct screening form for you to use can be found here: https://dc.medicatconnect.com/ For others, this form can only be completed if you meet ONE OR MORE of the following criteria: (1) You or a member of your household has recently visited a CDC level 2 or 3 country (China, Iran, South Korea, Japan and several European countries (see them here)) (2) You or a member of your household has recently traveled to any other areas where the spread of coronavirus is a concern (3) You or a member of your household is exhibiting symptoms such as fever, cough, or shortness of breath (4) You or a member of your household has been exposed to anyone suspected or confirmed to have novel coronavirus. Do you meet ONE OR MORE of these criteria?* Yes No Thank you for participating in this survey. As you do not meet any of the criteria, no further information is required. You do not need to continue or submit the form. Personal Information Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Please select your primary College status:* Student Employee Please select your housing status* Commuter Live on Campus Live near campus (Off Campus Housing) Thank you for participating in this survey. As you do not meet any of the criteria, no further information is required. You do not need to continue or submit the form. Instructions Please read each question and mark the box next to your answer (“Yes,” “No,” or “Unsure”). Please consider yourself, and members of your household, when answering. This is an effort to gauge the extent to which the College community may be exposed to the coronavirus. The Health Center will let you know if further steps are necessary before you can return to campus. Your answers will be shared with the Health Center, and other essential personnel. Over the last two weeks did you travel to China, South Korea, Iran, Japan, Hong Kong or any European country??* Yes No Unsure Where did you travel?Over the last two weeks did you travel to any other areas where the spread of coronavirus was a concern?* Yes No Unsure Where did you travel?Do you live in an area where the spread of coronavirus is a concern?* Yes No Unsure Where do you live?*Have you, or anyone in your household, been exposed to a suspected or confirmed case of coronavirus in the past 14 days?* Yes No Unsure Are you, or anyone in your household, exhibiting any signs of illness? (Select all that apply)* Fever Coughing Shortness of breath Other No symptoms What symptoms are you experiencing*Thank you for participating in this survey. As you do not meet any of the criteria, no further information is required. You do not need to continue or submit the form.NameThis field is for validation purposes and should be left unchanged.
