Communicable Disease Screening and Attestation Adapted from Rocky Vista University Communicable Diseases Policy. Revised October 12, 2020.The online screening and attestation form must be completed on the day of entry, prior to campus access. Any person who is symptomatic with a suspected or confirmed communicable disease of a current epidemic or pandemic (i.e. Influenza or COVID-19) or who may have had a high risk exposure to the disease agent are prohibited from entering RVU buildings for the protection of the RVU community. The included screening questions will be used to help stratify the risks associated with potential exposures. Please answer the following questions:Name* First Last Phone*Email address:* Enter Email Confirm Email RVU Student, RVU employee, or contractor/invited guest?**** Please note that other visitors without a prior invitation or authorization are not currently permitted on campus due to RVU's COVID-19 campus restrictions.RVU StudentRVU EmployeeContractor/Invited GuestOrganization/Reason for visit:*Who invited or contracted you to come on campus?*Campus:*ColoradoUtahWhich class?*MSBSOMS IOMS IIOMS IIIOMS IVPA IPA IIPA IIIIn the past 48 hours, have you experienced any of the following possible COVID-19 symptoms (fever (> 100.4 F), chills, shortness of breath or difficulty breathing, new loss of taste or smell, vomiting or diarrhea)?*YesNoPlease indicate which symptoms you have experienced.*Select all that apply. Fever > 100.4 F Chills Shortness of breath or difficulty breathing New loss of taste or smell Vomiting Diarrhea In the past 48 hours, have you experienced 2 or more of the following possible COVID-19 symptoms (nausea, cough, fatigue, muscle or body aches, headache, sore throat, nasal congestion, runny nose) that are not attributed to a chronic or known condition (eg. seasonal allergies, migraines)?*Only answer yes if you have experienced 2 or more of these symptoms.YesNoPlease indicate which symptoms you have experienced.*Select all that apply. Nausea Cough Fatigue Muscle or body aches Headache Sore Throat Nasal congestion Runny nose In the last 14 days, have you been directly exposed to anyone who has tested positive for COVID-19 (within the last 3 weeks), a suspected person currently under investigation (test results pending), or a presumed positive person?*YesNoWho was the person with which you were in contact?*RVU studentRVU employeeOtherPlease specify (patient, family member, etc.)*What is the COVID-19 test status of the person with whom you were in contact in the last 14 days?*Was that person symptomatic at time of contact?*YesNoUnsureWere you and the person both wearing PPE during entire time of contact?*YesNoPlease describe below specifically, surgical mask, gown, etc.*Has this case been discussed and cleared by a COVID-19 Response Team Medical Officer?*YesNoPlease select the officer with whom you spoke about the above:*Please select.Dr. David ParkDr. Dennis KinderDr. Andrew AmblerIf you have been assessed by a COVID Response Team medical officer, you would have been e-mailed a PDF copy of your assessment. Please upload that document here:* Drop files here or Accepted file types: pdf. Is there anything else we should know concerning your current condition that is relevant to the Communicable Disease Policy of Rocky Vista University?By signing my name below, I attest that I have answered all the questions above truthfully to the best of my knowledge. Deliberately providing false information on this attestation will initiate an investigation and may result in disciplinary action. I further attest that I will notify my appropriate manager or curriculum leader immediately should I develop any symptoms of the communicable disease. I understand the purpose of this form and protocol is to assist Rocky Vista University with providing a safe workplace for all employees and students. I further understand that Rocky Vista University is encouraging all employees and students to follow best practices issued by the Centers for Disease Control and Prevention and to stay home if I am ill or have a family member who is ill.*This form is used as a screening protocol only and should not be considered medical care. Rocky Vista University complies with the HIPAA security rule for all covered entities and conducts an annual security risk assessment. All electronic medical information will remain secure following all HIPAA policies and procedures as set forth in the HIPAA policy and procedure manual.