UIndy Health Check—Semester II Everyone in our UIndy community is required to use the UIndy Health Check each day that you plan on coming to campus. You must complete the form on the day—NOT the day before—you will be: coming to campus OR attending a university sanctioned or sponsored event, including internships, practicums, and field experience Based on the results of this form, you will receive a daily approval to be on campus, or a communication from UIndy’s contract tracing team about your next steps.My primary role at UIndy is:*Resident Student (Residence Halls & Campus Apartments)Commuter StudentFacultyStaffName* First Last UIndy Email Address* Phone Number*Please enter the best phone number to reach you.Special Note about the Start of Semester IIAs we prepare for the Second Semester, you will be required to complete this new health screening survey before you can return to campus. Please note that there are additional requirements in order to be cleared for a safe return to campus following the winter break - your answers to these questions will alert you as to whether or not you need a negative COVID-19 test before your return. Should you require a COVID-19 test prior to returning to campus, you must contact the Health and Wellness Center at (317) 788-3437 to schedule a test. If you have any questions about your safe return, please feel free to contact the Contact Tracing Office at firstname.lastname@example.org or or Kory V. at (317) 523-1609. Please complete the following questions prior to your initial return to campus after winter break. Are you planning to return to campus today for the first time after Winter Break?*YesNoWithin the last 10 days, I have:check all that apply traveled outside the state of Indiana attended a gathering of 25 or more people worked in a setting where there has been been a known, or elevated risk of, exposure to COVID-19 Have you received a negative COVID-19 test result since the activity or activities listed above?*YesNoAdditional Screening QuestionsHave you been tested for COVID-19 within the past 7 days?*If you were recently selected for surveillance/random testing by the University or completed return to campus testing you do not need to answer yes.YesNoWhat were the results of your test?*I'm waiting on results.My test results were NEGATIVE for COVID-19.My test results were POSITIVE for COVID-19.I am currently experiencing the following symptoms: Fever or chills NEW Cough Shortness of breath NEW Loss of taste or smell Sore throat Congestion or runny nose (excluding seasonal allergies) NEW unexplained fatigue Muscle or body aches Nausea or vomiting NEW Headache Diarrhea I am not experiencing any symptoms listed above.* Correct, I am not experiencing any symptoms. Within the past 48 hours, have you been in close contact with someone who tested positive for COVID-19?*Close contact is defined as less than 6 feet away for more than 15 minutes.YesNoNotice and Consent*The novel coronavirus (COVID-19 been declared a worldwide pandemic by the World Health Organization and a public health emergency by civil authorities. As part of its comprehensive COVID-19 plan, UIndy has launched a UIndy-created and owned Health Check web form (the “Web Form”) for COVID-19 symptom reporting and contact tracing purposes. The Web Form is a web-based form residing on UIndy’s systems and is accessible through MyUIndy. On a daily basis, all data provided through the Web Form will be used for contact tracing purposes. The data will be stored in its original form no longer than one week. Each week, the identifying information in the data held in the Web Form will be expunged and only de-identified aggregate data will remain. UIndy does not sell, or allow any research to occur with, any data submitted through the Web Form and does not use it for any purpose other than daily health screening and contact tracing. During the one week period that data is retained on UIndy’s system, UIndy may be required to disclose this data collected through the Web Form to other relevant organizations who require the data. For example, UIndy contact tracing is required to report its findings to local and state health departments and other public or occupational health agencies or through subpoena or valid court order. Should this occur, UIndy will ensure that such disclosures are limited to the minimum necessary under applicable law or legal process. Your consent, your use of the Web Form, and your submission of data is voluntary. By checking the box below, you consent to use the Web Form and accept the terms and conditions contained in this NOTICE AND CONSENT. You may revoke your consent at any time by sending an email to email@example.com; however, a decision not to participate by using the Web Form or an alternative provided by the University will result in your exclusion from campus until such time that UIndy discontinues use of COVID-19 symptom screening protocols. Your revocation is effective only upon the University’s receipt in writing of your request and will not affect any activities occurring prior to the effective date of your revocation notice. If you decide NOT to use this Web Form, you must complete a paper screening form before you can return to campus. You should know that the paper screening forms do not allow UIndy to quickly connect you to the contact tracing process, and you are strongly encouraged to use the Web Form. You may be asked at any time by any faculty, staff or administrator to produce proof of your approval to be on campus. I agree to the Notice and Consent.By clicking the SUBMIT button below, I affirm that any information I submit through the UIndy Health Check Web Form is true and accurate to the best of my knowledge and that all information I submit is specific and personal to me as the Web Form user. I understand that if I submit false information using the name and/or email address of any other person, I may be subject to disciplinary action for violation of UIndy policies and codes of conduct.