COVID-19 Screening and Reporting Tool

Visitor Information

First Name

Last Name

Email

Phone Number

Reason for visiting campus

Visit Information

Primary Role

Job Title

Contact person at OU

Contact person phone number

Department/College

Building(s) to be visited

Campus

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

Select all countries traveled

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

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

Vaccination Information

Have you received a COVID-19 vaccination?

Yes
No

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

COVID-19 Screening and Reporting Tool - Visitor