1. COVID-19 VISITOR Self-Screening Tool
    1. To be completed daily, prior to any on-campus activity

 

 

COVID-19 VISITOR Self-Screening Tool

 



To be completed daily, prior to any on-campus activity
 

Name: ___________________________________________________________

Contact Number: ___________________________________

Date: __________________ Site/Building:_______________________

Purpose of Visit: ______________________________________________________________________________

1.   Temperature taken at point of entry: ______________________

 

2.  Do you have a cough?             Yes No   

 

3.  Are you Short of Breath?             Yes No   

 

If yes:

When? ____________________________________________

                   Have you been in contact with a healthcare provider? Yes No   

        

4.  Have you traveled in the past 14 days?        Yes No   

If yes:

Where? __________________________________________________

When? ________________________________________________________

 

5.  Have you been in contact with anyone who has been diagnosed with

COVID-19?              Yes No   

 

If yes, when: _________________________________________________

       

6.  Have you been in contact with anyone that has had a cough, shortness of Breath or a fever in the past 14 days?          Yes No   

 

If Yes, when: _________________________________________________________________

 


You are consenting to a temperature scan, and you are affirming and attesting that the answers provided above are true and accurate. In the event you begin to feel sick on campus with any of the noted symptoms, you agree to notify Campus Police immediately.
 
Although Delgado Community College is taking appropriate and significant precautions to ensure and maintain a safe and sanitary environment, you are ultimately responsible for following the safety guidelines provided to you (i.e., protective equipment, safe distancing, hand washing, etc.).
 

Visitor’s Signature:               

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Revised 6/2/2020