UIndy Health Check 21-22 This form is for UIndy students, faculty, and staff. The Health Check for Visitors form is available for UIndy visitors. All unvaccinated individuals are required to fill out the UIndy Health Check every day they come 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 an 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 Student Faculty Staff Name* First Last Email Address* Phone Number*Please enter the best phone number to reach you.Are you considered fully vaccinated from COVID-19?*Fully vaccinated is defined as two or more weeks passed a) since your second dose of the Pfizer or Moderna vaccine or b) since receiving the Johnson & Johnson vaccine. Yes, I am fully vaccinated. No, I am not fully vaccinated. Before coming to campus, all vaccinated students, faculty, and staff who are experiencing possible COVID-19 symptoms should call Contact Tracing at (317) 788-6131 between 9:00 a.m. and 4:30 p.m. or Kory Vitangeli at (317) 523-1609 before/after hours. Are you experiencing any of 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 Yes, I am experiencing one or more of the symptoms listed. No, I am not experiencing any of the symptoms listed. Within the past 48 hours, I've 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 Have you been tested for COVID-19 within the past 7 days?* Yes, I am waiting on results. Yes, I received a POSITIVE for COVID-19 result. No, I have not been tested or I have received a NEGATIVE for COVID-19 result. Notice 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 firstname.lastname@example.org; 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.