Coronavirus (COVID-19) Status Report
What brings you to Maryville today?
What best describes you as a visitor:
Admissions Visitor
Contractor
Other Visitor
Move In/Out Guest
Faculty/Staff
Student
Full Name
Employer
Maryville Email Address
Email Address
Phone Number
This email will only be used for the purposes of this health survey. If you do not have an email address, please provide the email address of the prospective student.
Name of Person You're Meeting With
Title/Department of the Person You're Meeting With
If you are the guest of an Admissions Visitor, please indicate the prospective student’s name:
Move In Student You're Here With
Campus Residence Being Moved Into
Please read and check all statements that apply to you:
In the last 72 hours I have had a fever over 100.4F
In the last 72 hours I have experienced any of the following symptoms
that you cannot attribute to another health condition or to receiving your COVID vaccination
: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea.
I
n the last 10 days I have had close contact for any length of time (within 6 feet) with someone known to have COVID-19.
In the last 5 days I have tested positive for COVID-19.
In the past 5 days, I have been tested for COVID-19 outside of Maryville University.
COVID-19 Test Date
COVID-19 Test Result
Please select...
Positive
Negative
Awaiting Results
Have you been within 6 feet of someone with COVID- 19 for 15 minutes or longer?
Please select...
Yes
No
Have you provided care to someone who is sick with COVID-19?
Please select...
Yes
No
Have you had any direct physical contact (touched, hugged, kissed) with a person who has COVID -19?
Please select...
Yes
No
Have you shared eating or drinking utensils with someone who is COVID- 19 positive?
Please select...
Yes
No
Has someone with COVID- 19 coughed/sneezed on you?
Please select...
Yes
No
* Health Professions faculty and students following the health and safety requirements at their workplace do not need to notify the University of potential workplace exposure to COVID-19; however, individuals are required to report development of COVID-19 symptoms or diagnosis consistent with the University's reporting requirements.
Acknowledgement
I understand this information will be used to determine whether I may be permitted to work on or visit campus for the day in question and will not be used for any other purpose. I understand accurate information is necessary to ensure the health and safety of Maryville’s campus community. By submitting my response to this survey, I certify and affirm the information I am providing is true and correct. The information gathered through this survey will be maintained in a confidential manner by Maryville University. Individuals who answer yes to any of the above questions are not permitted to be on campus and are encouraged to contact their health care provider.
Please select...
No - None of these apply to me
Yes - One or more of these apply to me
Have you been on campus in the last 5 days?
Please select...
Yes
No
Are you scheduled to be on-campus at all, for any reason, within the next 14 days?
Please select...
Yes
No
When are you next scheduled to be on campus?
Yes or Checked Boxes
Contact Information