Quarantine Questionnaire for Faculty/Staff

Please submit this form in order to indicate if you have had Close Contact with other individuals after being in close contact with someone who has tested positive.

Your Name Your Name First Last
Z Number
Your Cell Phone # Your Cell Phone # - ### - ### ####
ORU Email
I am a:

I am a: Faculty Member Staff Member
Office Location and Number
Have you experienced any COVID-19 symptoms since you were exposed to the individual who tested positive?

Have you experienced any COVID-19 symptoms since you were exposed to the individual who tested positive? Yes No

COVID-19 has a wide range of symptoms reported – from mild symptoms to severe illness.

Symptoms may appear 2-14 days after exposure to the virus.

People with these symptoms may have COVID-19:

- Fever or chills
- Cough
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Diarrhea
Have you notified ORU community members with whom you have been in Close Contact?

Close Contact with someone who has COVID-19 as described by the CDC occurs when:

• You were within 6 feet of someone who has COVID-19 for at least 15 minutes
• You provided care at home to someone who is sick with COVID-19
• You had direct physical contact with the person (touched, hugged, or kissed them)
• You shared eating or drinking utensils
• They sneezed, coughed, or somehow got respiratory droplets on you

Have you notified ORU community members with whom you have been in Close Contact?

Close Contact with someone who has COVID-19 as described by the CDC occurs when:

• You were within 6 feet of someone who has COVID-19 for at least 15 minutes
• You provided care at home to someone who is sick with COVID-19
• You had direct physical contact with the person (touched, hugged, or kissed them)
• You shared eating or drinking utensils
• They sneezed, coughed, or somehow got respiratory droplets on you Yes No
When were you last on campus? When were you last on campus? / MM / DD YYYY
Please list the names of the individuals with whom you have had Close Contact on campus since you came into contact with the person who tested positive
In the past two days, how many people have you been in Close Contact with?
#1 Close Contact Name:
#1 Close Contact email:
#1 Close Contact Phone Number:
#2 Close Contact Name:
#2 Close Contact email:
#2 Close Contact Phone Number:
#3 Close Contact Name:
#3 Close Contact email:
#3 Close Contact Phone Number:
#4 Close Contact Name:
#4 Close Contact email:
#4 Close Contact Phone Number:
#5 Close Contact Name:
#5 Close Contact email:
#5 Close Contact Phone Number:
Please list the Names, Email addresses, and Phone Numbers for any other individuals with whom you had Close Contact:
Please list the ORU Campus locations (Classroom Number, offices, meeting area, etc.) you have visited.

Ex: LRC 3 Bookstore
Notify your Supervisor
I want this form to automatically notify my Supervisor/Co-Workers that I will be working in a virtual setting or isolating until I am free of COVID-19 symptoms for 10 days

I want this form to automatically notify my Supervisor/Co-Workers that I will be working in a virtual setting or isolating until I am free of COVID-19 symptoms for 10 days Yes, please use this form to notify my supervisor(s)
How many people do you want to notify?
#1 Recipient email:

Please provide @oru.edu email addresses
#2 Recipient email:
#3 Recipient email:
#4 Recipient email:
#5 Recipient email:
#6 Recipient email:
#7 Recipient email:
As you submit this form, the individuals for whom you have provided contact information may be contacted for more information. Do you understand and give consent for this notification to occur?

As you submit this form, the individuals for whom you have provided contact information may be contacted for more information. Do you understand and give consent for this notification to occur? I understand and give consent for the notification described in the above paragraph to occur.
Email
Type the letters you see in the image below.

Quarantine Questionnaire for Faculty/Staff

Quarantine Questionnaire for Faculty/Staff

Please list the names of the individuals with whom you have had Close Contact on campus since you came into contact with the person who tested positive

Notify your Supervisor