Emmaus Guest Health Screening Form
Each guest who will be present for a campus visit must complete this form 24 hours before arrival to campus. This form will be kept private and only shared with members of the COVID-19 TaskForce and medical personnel as needed. (As a reminder, guests of students are only allowed in outdoor spaces at this time and requests for multiple guests will not be approved at this time e.g. a party or group event hosted on campus.)
Email address *
Guest Name *
Who are you visiting?
Hometown and State *
Your Current Temperature *
Please take an accurate current temperature using a digital thermometer within 24 hours of traveling to Emmaus.
Where have you lived/worked in the past 14 days? *
Please all applicable include cities, states, and companies.
Where have you traveled during the past 14 days, domestically or internationally? *
Include all relevant cities, states, or countries. If you have not travelled, write N/A.
In the past 14 days, have you had contact with anyone who has traveled internationally? *
If Yes, please explain
Have you had close contact or cared for an individual who has exhibited symptoms or tested positive for COVID-19 in the past 14 days? *
If Yes, please explain
Have you had positive test in the last 14 days?
Clear selection
Please explain including test date, protocols being taken, etc.
In the past 14 days, have you experienced any of the following symptoms? *
Check all that apply. If none describe you, check N/A.
Required
According to the Centers for Disease Control (CDC), people 65 years or older and people with the following conditions are considered high-risk for serious infection should they contract the virus:
If any of the following describe you, please consult your physician prior to attend move-in days.
If you agree with the following statement, please print your name: *
For the safety of the Emmaus community, I hereby confirm that I have answered all questions truthfully and included all necessary information about my health history as related to COVID-19. I understand that my answers to these questions may affect my ability to come to campus. I also assume all liability and responsibility related to potential COVID-19 exposure during my time at Emmaus. Lastly, I agree to abide by all campus policies including the wearing of masks in all indoor spaces and during select outdoor activities, and maintaining social distancing at all times. (See your host for more information.)
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