Health Screening Form

Personal Information

To better serve you and our community, we are asking all students to fill out this survey during the COVID-19 pandemic.

Name

First Last

Email

Phone

Do you currently have health insurance?*

If yes, who is your Medical Insurance Provider?

Policy Number

COVID – 19 Testing & Symptoms

Have you in the last two weeks had close contact with someone who has tested positive for COVID-19?*

Do you currently have any symptoms of COVID-19? Please check all that apply*

We understand that just because you may have some of these symptoms, it does not necessarily indicate that you have COVID-19. Please provide additional details for any symptoms you check in the Comments box.

Comments

Health History

People with certain health conditions have been encouraged by the CDC to take extra precautions. This list of underlying conditions is meant to inform individuals as to what their level of risk may be so they can make individual decisions about illness prevention. Please select any underlying health conditions you have, you may use the comment box below for clarifying if needed.

Please select:

Comments

Do you have any concerns about your personal health in relationship to COVID – 19?

Emergency Contact

Please list 2-3 contacts you approve Portland Bible College to reach out to in case of an emergency.

(1) Emergency Contact*

First Last

Phone*

Relationship to Student*

(2) Emergency Contact*

First Last

Phone*

Relationship to Student*

(3) Emergency Contact

First Last

Phone

Relationship to Student