EmailMeForm
Staff Campus Visitation Form (Check IN)
Please inform us when you are planning to come into campus.
Name
*
First
Last
Email
*
Employee No:
*
Contact Phone#
*
###
-
###
-
####
Date Time - Planning to arrive on campus
*
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
What room will you be in?
*
COVID Questionnaire
Please answer the questions below
Have you been diagnosed with or suspected to have COVID-19 in the last 14 days?
*
YES
NO
Have you taken medication to reduce fever in the last 14 days?
*
YES
NO
Have you had contact with another person who is confirmed or suspected to have COVID-19 in the last 14 days?
*
YES
NO
Have you had one or more of these symptoms in the last 14 days? (Check all that apply)
*
Fever at or greater than 99 degrees
Shortness of breath or difficulty breathing
Loss of taste or smell
Cough
Chills
Muscle pain
Headache
Sore throat
Vomiting or diarrhea
None of the above
HOLD down Ctrl for multiple select
Is today a required work day for your Basis?
*
YES
NO
N/A
If you answered No or N/A above, please mark the most appropriate reason.
*
I am volunteering
I have a special appointment/meeting I am attending voluntarily
I marked yes above
