JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
COVID-19 Student Self Screening Assessment
Centre for Nursing Studies
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
IMPORTANT If at the completion of the self-assessment you are directed to contact 811, please immediately contact your clinical or lab instructor to notify them that you must self-isolate until your symptoms are assessed by 811.
When you submit this form, you will be directed to a confirmation screen. This will have a link to the assessment you need to fill out. Please select "Yes" to indicate you are going to fill out the form:
https://covidassessment.nlchi.nl.ca/
*
Yes, I am going to click the link to fill out the Form.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Memorial University of Newfoundland.
Report Abuse
Forms
