The safety of the entire University of Evansville community is a top priority. As the COVID-19 outbreak continues to be a potential threat, the University is monitoring the situation closely.

To prevent the spread of COVID-19 and reduce the potential risk of exposure, we are requiring everyone who is approved to be on campus to complete this COVID-19 Self-Screening Questionnaire. Your participation is important to help us take precautionary measures to help protect you and everyone on campus.

1.	Today's Date

3.	Reporting time:*

4.	First Name*

5.	Last Name*

6.	Email Address*

7.	Mobile phone number*

9.	Have you taken any over the counter medication in the last 24 hours (cold medication, acetaminophen, ibuprofen)?

10.	Do you have congestion or runny nose? *
	YesNo

11.	Are you currently experiencing any of the following symptoms? Fever Cough Shortness of breath or difficulty breathing Chills Repeated shaking with chills Muscle pain Headache Sore throat New loss of taste or smell Lack of appetite, diarrhea, and vomiting *
	YesNo