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Health Screening Form - Self Reported Data

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Please Login

8-digit Student ID :
* Required

One of the below is required.
Birth Date:
see Instructions
Last 4 digits of SSN:

   Login Instructions

  • Student ID is required, it is your 8-digit Student/Employee ID assigned by the Institution (this is NOT your StarID).
  • One of the following is also required:
    • Birth Date, which must be in YYYYMMDD format.
          Example May 23, 1969 would be: 19690523
    • Last 4 digits of SSN (Social Security Number)
  • At the end of your login session, you must 'Logout' to ensure that nobody else can access your records using your computer.


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