Walsh Health Screening Form

Name:
Email:
Phone:
Check One
Student/Visitor Employee
    Do you have any of these symptoms?
  • Fever (over 100.4°F or 38°C) or feeling feverish
  • Recently exhibiting shortness of breath
  • Recent coughing or worsening cough
YES NO
    Do you have two of any of these symptoms?
  • Chills
  • Muscle aches
  • New runny nose, nasal congestion, or sore throat
  • New loss of sense of smell or sense of taste
  • Headache
  • Diarrhea
  • Rash
YES NO
    Have you had close or household contact in the last 14 days with someone diagnosed with or exhibiting symptoms of COVID-19?

    (Close contact means being within 6 feet for ≥15 minutes)

YES NO
    Have you travelled internationally by airplane within the last 14 days?
YES NO

Date:


Walsh is accredited by the Higher Learning Commission ( www.hlcommission.org; phone: 312-263-0456). Specific degree programs are accredited by the Accreditation Council for Business Schools and Program (ACBSP, www.acbsp.org).
Administrative Offices are located at 3838 Livernois Rd, Troy, MI 48083. Additional locations in Michigan: Novi, Clinton Township, and Port Huron.

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