IMPORTANT: ALL Students To Return Completed Record ONE (1) Week Prior To Start of Electives
IMPORTANT: ALL Students To Return Completed Record ONE (1) Week Prior To Start of Electives
IMPORTANT: ALL Students To Return Completed Record ONE (1) Week Prior To Start of Electives
1a.
Do you have flu-like symptoms (i.e. fever and / or cough) in the last 14
days?
Yes / No
(Please
circle
accordingly)
Have you travelled or lived overseas in the last 14 days before the onset
of symptoms?
1b.
If yes,
Countries1 (Middle Eastern):__________________
Countries (Others) : _____________________________________
Yes / No
(Please
circle
accordingly)
2.
If yes, Countries:_____________________________________________
If Fever, state highest recorded Temp: _______ and date: __________.
Current Temperature: ____________________________
(State NA if temperature not taken)
Yes / No
(Please
circle
accordingly)
Yes / No
(Please
circle
accordingly)
4.
Relationship
Mother
(2)
1 High Risk Countries (for MERS-CoV) Middle Eastern: Jordan, Kuwait, Lebanon, Oman,
Qatar, Saudi Arabia, United Arab Emirates & Yemen
2 High Risk African Countries (for Ebola) include: Guinea & Sierra Leone
SELF-SURVEILLANCE GUIDELINES (14 days prior to commencement of electives)