Staff and Visitor Health Screening
This form must be completed in order to gain admittance into the building
First Name *
Last Name *
Today's Date *
MM
/
DD
/
YYYY
Are you a staff member? *
If you are not a staff member, please state the nature of your business.
In the past 14 days have you experienced any of the following symptoms?
In the past 14 days have you or anyone in your household been in close proximity to anyone who was experiencing any of the above symptoms, tested positive for COVID-19 or has experienced any of the above symptoms since your contact?
Clear selection
Have you or anyone in your household been tested for COVID-19 and are waiting to receive test results?
Clear selection
Please enter any pertinent information to explain a yes response to any of the above questions.
I certify that all information I have provided in this application is correct and complete.
Submit
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