Request edit access
COVID-19 Bethany College Health Screen
BEFORE YOU COME TO BETHANY COLLEGE CAMPUS, be sure that you can agree to every question herein, and  take a temperature, have no symptoms, and wear a mask on campus!.

If possible, please consider conducting your business remotely through email or phone. See the directory for contact information at  www.bethanylb.edu/directory
.
Sign in to Google to save your progress. Learn more
First and Last Name *
Phone number *
Email *
Date of Visit (must be completed the day of the visit) *
MM
/
DD
/
YYYY
ANSWER QUESTIONS ABOUT YOUR HEALTH
Before you answer the following, you should review McPherson Co Health Dept at  mcphersoncountyks.us/866/COVID-19-Resources,  and CDC guidelines at www.cdc.gov/coronavirus/2019-ncov/index.html for the most up to date recommendations.
Verify that you NOT been exposed to anyone with known COVID in the past 14 days or traveled to any locations that require quarantine by McPherson County? (If you have- DON'T come to campus ) *
Required
Do you have any of COVID symptoms as currently listed by the McPherson Co Health Department: chills, muscle aches, cough, sore throat, diarrhea, trouble breathing or shortness of breath? If you DO, DON'T come to campus! *
Required
After taking your body temperature within the past two hours, you can verify your body temperature was  lower than 100.4 degrees F? *
Required
Estimated Time of Visit (be as liberal as possible) *
I will be in the following buildings on campus (check all that apply) *
Required
Do you agree you will wear a mask on campus in all public spaces, and social distance from others and respect employee contact preference? (you must have a mask or you will be asked to leave- we will not have one for you if you are not an employee or student) *
Required
If at any time on campus you come down with symptoms listed herein, you agree to leave immediately and notify the last person you saw, and the campus nurse by email healthservices@bethanylb.edu immediately *
You agree that because of the nature of COVID-19, there is always a potential for exposure in places open to the public. All implemented health precautions require your cooperation and diligence! *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bethany College.

Does this form look suspicious? Report

Google Forms