Health Screening Form | Eastern New Mexico University

Date

Name*

First Last

Email*

Supervisor or Instructor Name*

First Last

The following list is not all inclusive and employees should look at the CDC website for the latest updates and symptoms.

Do not come to work or class if you are showing any of these signs. Please contact your medical provider, or La Casa Health Services at 575-624-4120 to schedule a medical appointment.

• Fever over 100.3
• Cough
• Shortness of breath
• Nasal congestion
• Nausea
• Diarrhea
• Sore throat
• Headache
• Muscle pain
• Chills
• Repeated shaking with chills
• Loss of taste or smell

Since your last day of work, or last visit here, have you had any of these symptoms that is not attributable to another condition?*

No
Yes

Have you, or anyone you have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19?*

No
Yes

Have you been asked to self-isolate or quarantine by a medical professional or a local public health official?*

No
Yes

Verification*

Verify

Check this box to affirm you are not exhibiting any symptoms listed above, and the information you have provided for this application is complete, accurate and true to the best of your knowledge. (Reminder: if you are coming on campus you will need to wear a mask in public spaces)

Buildings you will be visiting (select all that apply)?*