UIndy Health Check for Visitors All visitors, whether vaccinated or not, should follow the campus visitor guidelines and complete this UIndy Health Check for Visitors before coming to campus. Students, faculty, and staff need to use the UIndy Health Check form instead.Have you been tested for COVID-19 within the past 7 days?*If you were recently selected for surveillance/random testing by the University, you do not need to answer yes. Yes No What 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. Yes No Email Address* Notice and Consent*The novel coronavirus (COVID-19) has been declared a public health emergency and a worldwide pandemic. As part of its comprehensive COVID-19 plan, UIndy has launched a UIndy-created and owned Visitor Health Check web form (the “Web Form”) for COVID-19 symptom screening. The Web Form will be used to help visitors know, based on their symptoms, if they can come to campus or if they should stay away pending further guidance from their personal healthcare providers. Based on your answers to several symptom and other COVID-19 exposure questions, the system will notify you that you are cleared to come to campus that particular day or that you are advised not to come to campus. While on UIndy’s campus, you may be stopped and asked to display proof (the email approval you received) that you have been cleared to be on campus that day. Even if the Web Form clears you to come to campus that day, you understand that you are still at risk for exposure to COVID-19 due to its transmissibility even among asymptomatic individuals. The Web Form is a web-based form residing on UIndy’s systems. On a daily basis, all data provided through the Web Form will be used for symptom screening purposes, and data will be deleted after several hours. 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 symptom screening. In the unlikely event UIndy is required, by local and state health departments and other public or occupational health agencies or through subpoena or valid court order, to disclose any data not yet deleted and collected through the Web Form, UIndy will only disclose data in compliance with all applicable laws. By checking the box below, you consent to use the Web Form and accept the terms and conditions contained in this NOTICE AND CONSENT. Your consent, your use of the Web Form, and your submission of data is voluntary; however, a decision not to use the Web Form or an alternative provided by UIndy may result in your exclusion from campus until such time that UIndy discontinues use of COVID-19 symptom screening protocols. You may revoke your consent at any time by sending an email to firstname.lastname@example.org. 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. I agree to the Notice and Consent.By clicking the SUBMIT button below, I affirm that any information I submit through the Health Check for Visitors 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.