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YSU Post Travel Screening

In the interest of Public Health, please be honest as you complete this document in order to best serve you and the YSU Community. Information provided on this form will be forwarded for review by a licensed health care provider.

This question requires a valid email address.
5. YSU Status *This question is required.
6. Where do you currently reside?  *This question is required.
7. Following your travel, do you plan on returning to this location (from chosen above)? *This question is required.
10. Did you have any layovers and if so where?  *This question is required.
12. Do you have any of the following symptoms? (Select all that apply) *This question is required.
13. Have you had:  A fever or signs of lower respiratory illness AND close contact with a laboratory confirmed COVID-19 patient within the 14 days of symptom onset *This question is required.
14. Have you had: Fever and signs/symptoms of lower respiratory illness (e.g. cough or shortness of breath) requiring hospitalization AND history of travel from affected geographic areas within the 14 days of symptom onset (Current areas include: China, South Korea, Japan, Europe and Iran)? *This question is required.
15. Have you had: Fever with severe acute lower respiratory illness (e.g. Pneumonia, ARDS) requiring hospitalization and without alternative explanatory diagnosis (e.g. influenza) AND NO source of exposure identified? *This question is required.
16. Have you traveled to/passed through any of the following areas?  *This question is required.
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