Flu Symptom Questionnaire

Faculty and Staff experiencing acute/severe symptoms should seek immediate medical care by going to the Emergency room or the Shroyer Health Center.

This page is for Faculty and Staff; If you are a Student please click here to report your symptoms using the Student Questionnaire.

First Name:

Middle Name:

Last Name:

Building:

Date of onset:

Fever(sudden onset):

Highest recorded temperature:

Sore Throat:

Cough:

Aches:

Nausea:

Vomiting:

Diarrhea:

Headache:

Head Congestion:

Breathing Difficulty:

History of asthma:

Additional Information:

Are you going Home?