Report • CampusOptics

Public Health Assessment: This set of screening questions is to be completed for category 2 individuals who have been in the DRC, South Sudan, or Uganda in the last 21 days. If the answer to any of the questions B-H is ‘yes’, the individual is deemed high risk (category 2b), and is required to quarantine 21 days from the latest date of possible contact. In the "location" field, use one of the following location names that aligns with your campus presence: GU-Hilltop Campus, GU-Remote-Hilltop, GU-Capitol Campus, GU-Remote-Capitol, GU-Qatar, GU-Remote-Qatar, GU-MedStar Georgetown University Hospital, or GU-Off-site.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

Loading…

Basic Information

GU Net ID

A. Which affected country/countries were you in during the past 21 days?

Democratic Republic of Congo

South Sudan

Uganda

None of these

A. Date(s)

B. Were you present in any healthcare facility, such as a hospital, clinic, or traditional healer?

C. Did you provide health care, perform lab work, clean, or handle waste in a healthcare setting?

D. Did you have contact with or were you near a sick person with fever or other acute illness?

E. Did you come into contact with anyone's blood or other body fluids, such as vomiting, saliva, feces, or urine?

F. Did you touch a dead body, prepare a body, attend a funeral, or perform burial work?

G. Did you have contact with a bat, monkey or ape (alive or dead)?

H. Did you go into a mine or a cave?

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.