教师 & 工作人员 Self-Reporting Portal - pg电子下载 State University-pg电子下载

pg电子下载 State University is dedicated to protecting the well-being of its students, 教师, 工作人员, and campus community. The University requires all students, 教师 and 工作人员 to inform pg电子下载 officials about any recent travel, possible 新型冠状病毒肺炎 related exposures, and/or associated illness through the self-reporting form. Employees will be will be 要求 to self-monitor their own health daily and contact pg电子下载 State 健康服务/or their medical provider if they are symptomatic and/or exposed to 新型冠状病毒肺炎. Your information will be submitted to the Office of Human Resources and will remain confidential.

Please use the self-reporting forms to provide details regarding your recent travel, possible 新型冠状病毒肺炎 related exposures, and/or associated illness. 谢谢你！!

第一个名字 *

身份证号码 *

电子邮件地址 *

电话号码 *

Academic School/Department *

姓 *

办公室电话 *

List All Buildings Occupied *

Contact with 新型冠状病毒肺炎

Have you had recent contact with someone who has been diagnosed with 新型冠状病毒肺炎? *

是的

Please describe your last contact visit with this person.

Have you had recent contact with someone suspected of having 新型冠状病毒肺炎? *

是的

Please describe your last contact visit with this person.

Are you having flu-like symptoms including fever, cough, or shortness of breath? *

是的

If yes, when did your symptoms start?

Have you been tested for 新型冠状病毒肺炎?

是的

If yes, what are your test results or when are your test results expected?

Have you received a 新型冠状病毒肺炎 vaccine? *

是的

Which vaccine have you taken?

When did you receive your first dose?(mm / dd / yyyy)

When did you receive your second dose?(mm / dd / yyyy)

Are you feeling sick? *

是的

If yes, describe all your symptoms.

Have you received a 新型冠状病毒肺炎 vaccine booster? *

是的

Which vaccine booster have you taken?

When did you receive your booster dose? (mm / dd / yyyy)

Have you received a second 新型冠状病毒肺炎 vaccine booster? *

是的

Which vaccine booster have you taken the second time? *

When did you receive your second booster dose?(mm / dd / yyyy) *

Have you received a 3rd 新型冠状病毒肺炎 vaccine booster? *

是的

Which vaccine booster have you taken the third time?

When did you receive your third booster dose?(mm / dd / yyyy) *

Do you live on campus (on-campus housing)? *

是的

Have you recently traveled in the last two weeks? *

是的

Start Date of Travel:(mm / dd / yyyy) *

End Date of Travel:(mm / dd / yyyy) *

Please list cities, states, countries.

Have any other pg电子下载 employee traveled with you? *

是的

If yes, please list their name(s). *

Please give any additional information you feel is pertinent. *

Please send a confirmation email to the address below*:

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