COVID-19 Workplace Health Screening

To ensure compliance with Governor Gretchen Whitmer’s “Stay Home, Stay Safe” executive order, we have provided a Coronavirus Disease (COVID-19) Workplace Health Screening form to be used by faculty, staff and students involved in essential operations EACH TIME they are visiting an MSU-affiliated facility during the affected time period.

COVID-19 Workplace Health Screening Online from

Faculty, staff, and students who are performing essential operational functions on campus or at another affiliated location should complete this form PRIOR to visiting an MSU affiliated facility on the day of the planned visit. After completing the form, you may proceed to the location of work only if you respond “no” to ALL of the screening questions. It is also important to observe social distancing measures while at the worksite. You are required to maintain a distance of at least six feet from others, practice recommended hand washing hygiene, use appropriate personal protective equipment, and remain on campus the least amount of time possible to complete your work.

Paper copies of the form are also available. If you choose this option, completed forms should be forwarded to the HR Director to keep on file. Forms can be emailed to The health care screening form must be completed for any planned visit to campus or the Community Music Schools in East Lansing and Detroit. The records kept are needed to demonstrate compliance with the executive order.

Downloadable Form (PDF)

If you have questions about any of the information collected in this form or why this information is required, please contact your supervisor.