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
Travel History
Have you traveled to the United States from another country (does not apply to US territories) within the past 14 days?
Yes
No
Have you been on a river or ocean cruise, domestic or international, within the last 14 days?
Yes
No
Date you returned to/arrived in the United States
Date you disembarked from the cruise ship
Select all countries traveled
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ashmore and Cartier Islands
Austria
Australia
Azerbainjan
Bahrain
Baker Island
Bangladesh
Barbados
Bassas Da India
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burma and Myanmar
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, Democratic
Congo, Republic of the
Cook Islands
Coral Sea Islands
Costa Rica
Cote D' Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Eastern Mediterranean (defined by CDC)
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Europa Island
Europe, including the UK
Falkland Islands (Islas Malvinas)
Faroe Islands
Fiji
Finland
Forfolk Island
France
French Guiana
French Plynesia
French Southern & Antarctic Lands
Gabon
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guam
Guana
Guatemala
Guernsey
Guinea
Guinea-Bissua
Haiti
Heard Island & McDonald Islands
Holy City (Vatican City)
Honduras
Hong Kong
Howland Island
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Jan Mayen
Japan
Jarvis Island
Jersey
Johnston Atoll
Jordan
Juan De Nova Island
Kazakhstan
Kenya
Kingman Reef
Kiribati
Korea North
Korea South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lestho
Liberia
Libya
Liechtenstien
Lithuania
Luxembourg
Macau
Macedonia, The Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Man, Isle of
Marshal Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Midway Islands
Moldova
Monaco
Mongolia
Montenergro
Montserrat
Morocco
Mozambique
Namibia
Nauru
Navassa Island
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palmyra Atoll
Panama
Papua New Guinea
Paracel Islands
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Romelin Island
Russia
Rwanda
S. Korea
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Soloman
Soloman Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Spratly Islands
Spratly Islands PG
Sri Lanka
Sri Lanka CE
Sudan
Suriname
Suriname NS
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
The Bahamas
The Gambia
Togo
Tokelau
Tonga
Trinidad & Tobago
Tromelin Island
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu NH
Venezuela
Vietnam
Virgin Islands (U.S.)
Wake Island
Wallis and Futuna
West Bank
Western Sahara
Yemen
Zambia
Zimbabwe
To select multiple items hold the shift key for adjacent items and ctrl key for separated items.
Additional comments regarding travel
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
Vaccination Information
Have you received a COVID-19 vaccination?
Yes
No
Which COVID-19 vaccination did you receive?
Pfizer-BioNTech
Moderna
Janssen (J&J)
Other
Please specify:
COVID-19 vaccination
1st
dose date:
COVID-19 vaccination
2nd
dose date:
Additional comments regarding vaccinations
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