Health Screening Form

  • MM slash DD slash YYYY
  • 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

    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)