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Wellness Screening Questionnaire


Please answer the following questions on the day of your visit to Northeastern. You will be required to provide proof of the completed wellness screening questionnaire when you arrive on campus.

Are you experiencing any of the following symptoms?

  • New loss of smell or taste
  • New or worsened muscle aches
  • Fever, feeling feverish or shaking chills
  • New or worsened cough
  • New or worsened shortness of breath
  • New or worsened sore throat
  • Diarrhea/vomiting

☐  Yes ☐  No

If you are experiencing any of the above symptoms, please reschedule your visit and remain away from campus.

In the past 14 days, have you had close contact with someone who is confirmed as having COVID-19?

A close contact is defined as a person who:

  • Provided care for the individual, including healthcare workers, family members or other caregivers, or who had similar close physical contact without consistent and appropriate use of personal protective equipment


  • Who lived with or otherwise had close prolonged contact (within 6 feet/2 meters) with the person while they were infectious


  • Had direct contact with infectious bodily fluids of the person (e.g., was coughed or sneezed on) while not wearing recommended personal protective equipment

☐  Yes  ☐  No

If you have been in close contact with someone who has COVID-19 in the past 14 days, please reschedule your visit and remain away from campus.


I will comply with all local and state guidelines related to COVID-19, including travel guidelines that may require me to show proof of a negative COVID-19 test within the last 72 hours or quarantine for 14 days. Northeastern reserves the right to request proof of your compliance with local and state guidelines.

☐  Yes  ☐  No


I will comply with Northeastern’s COVID-19 related protocols, including wearing a face covering, maintaining a healthy distance from others, complying with entry/exit protocols, and practicing good personal hygiene.

☐  Yes  ☐  No

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