COVID-19 Screening and Reporting Tool - Visitor
Visitor Information
First Name
Last Name
Email
Phone Number
Reason for visiting campus
Username
Visit Information
Primary Role
Job Title
Contact person at OU
Contact person phone number
Department/College
Building(s) to be visited
Campus
OKC
Tulsa
Norman
Lawton
Expected date of arrival to campus/workplace
Symptom Information
Have you experienced any symptoms within the last 14 days?
Yes
No
Experiencing chills?
Yes
No
Experiencing congestion or runny nose?
Yes
No
Experiencing cough?
Yes
No
Experiencing diarrhea?
Yes
No
Experiencing fever?
Yes
No
Experiencing headache?
Yes
No
Experiencing loss of taste or smell?
Yes
No
Experiencing muscle pain?
Yes
No
Experiencing nausea or vomiting?
Yes
No
Experiencing shortness of breath?
Yes
No
Experiencing sore throat?
Yes
No
Experiencing other symptoms?
Date of Onset of First Symptom
Have all of your symptoms resolved?
Yes
No
Date symptoms resolved
Additional comments regarding symptoms
Exposure Information
Have you been within 6 feet for 15 minutes or longer with someone with Confirmed (+) COVID-19 within the last 14 days?
Yes
No
Have you been within 6 feet for 15 minutes or longer with someone awaiting COVID-19 test results within the last 14 days?
Yes
No
Is this person a member of your household?
Yes
No
Date this person tested positive (or date of test if results still pending)
Date this person developed symptoms
When were you last exposed to this person?
Additional comments regarding exposure
Testing Information
Have you tested POSITIVE for COVID-19 within the last 14 days?
Yes
No
Positive test date
Positive test type
PCR
Rapid PCR
Rapid Antigen
Saliva test
Unknown
Test location
Access Medical Center
Cate Center
Classen Urgent Care
Cleveland County Health Department
Goddard Health Center
Immediate Care Urgent Care
IMMY
Other
Specific test location
Additional comments regarding tests
Acknowledgement
The information submitted on this form is complete and accurate to the best of my knowledge.
I acknowledge that this screening tool is being used for clearance to visit campus for the specified reasons and dates stated within this form, based on information I provided. It is not intended for use regarding personal medical evaluation, advice, decisions, and/or treatment. Seek care from your primary care provider or emergency services, as appropriate, for any personal medical needs.
I understand this information is being collected for the purpose of infection prevention and public/employee safety.
I Agree