COVID 19 Exposure Screening Questionnaire

COVID 19 Exposure Screening Questionnaire


TO OUR FACULTY, STAFF, STUDENTS, & VISITORS: For the safety and health of the SUSLA campus community, we ae screening all faculty, staff, students, and visitors to decrease the risk of infectious disease transmission among campus occupants. This approach is in line with scientific evidence regarding the spread of these types of diseases, and is meant not to alarm anyone, but to protect us all. We appreciate your understanding as we ask you to complete the questionnaire regarding your travel and health. If you are approved to remain on campus, you must comply with all campus instructions. In the case that you are not allowed on campus, please visit your healthcare provider.


Please respond to the following questions:

1. Have you had any of the following symptoms in the past 14 days?

2. In the past 14 days, have you been in close contact with anyone confirmed positive for COVID-19 (formerly known as “Novel Coronavirus”)?

3. Have you returned from U.S. travel within the past 14 days?

4. Have you returned from travel within the past 14 days from China, Iran, Italy, Japan, South Korea, or another foreign country?

If you’ve answered yes to any of the above-mentioned questions, you are not permitted on any SUSLA properties, practice social distancing, and please call your health provider or your State Department of Health for further direction.

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