Admission No:/JAMB No: Full Name
Faculty
Level of Study Age
Name of Next of Kin Address of Next of Kin
From where are you resuming to school  
Where did you lodge when you arrived in Sokoto  
     
Have you visited any of the following Countries of West Africa in the last twenty one (21) days? Yes No
(If yes tick as appropriate) Sierra Leone Guinea Liberia Kenya D.R Congo Senegal
Have you come in to physical contact with any Ebola patient during the last twenty one (21) days? Yes No
Have you suffered from any of the following symptoms during the last seven (7) days? (Tick as appropriate)  
Fever Sore throat Stomach Pain Joint and muscle aches
Lack of appetite Bleeding from nose Fatigue or Weakness Bleeding from Gums
Bloody diarrhea Headache Shortness of Breath Rash
Nausea or Vomitting Diarrhea Vomitting Blood Dark Urine
Suffered no symptoms