SARS Screening Form
Hiram College Health Center

Student Information

Last Name

First Name

Residence Hall

Phone

Circle All That Apply:
  • Travel in:
    Mainland China
    Hong Kong
    Singapore
    Taiwan
    Hanoi Vietnam
    Toronto, Canada
  • Close Contact:
    (Caring for, living with, or having direct contact with respiratory secretions or other body fluids from a person with SARS.)

Symptom Criteria:
  • Temperature > 100.4
  • Cough
  • Trouble Breathing
  • Headache
  • Body Aches
  • Chills

Date of onset of symptoms:

Students who meet definite contact criteria within the last 10 days and symptom criteria should be referred to the Emergency Department for evaluation.

Contact the Emergency Department of choice prior to making such a referral.

Additional Information