General COVID-19 Pre-Screening Form v4

All students, faculty, staff, vendors, and visitors MUST approach the COVID-19 screening stations at the campus entrances.

Pass/Fail Screening

Pass/Fail Screening Pass Fail
Visitor Type
Vendor/Contractor Name
Name Name First Last
Email
Phone Phone - ### - ### ####
Student ID
Maximum of 9 characters allowed. Currently Entered: 3 characters.
Visit Information
Area of Campus Visiting
Class Subject
Vaccination Assessment
Have you been fully vaccinated against COVID-19?

Have you been fully vaccinated against COVID-19? Yes No Prefer Not to Divulge
Symptom & Exposure Assessment
In the last 15 days, have you experienced mild to severe respiratory illness with any symptoms of fever, cough, and/or shortness of breath?

In the last 15 days, have you experienced mild to severe respiratory illness with any symptoms of fever, cough, and/or shortness of breath? Yes No
In the last 15 days, have you had a presumed or confirmed contact with anyone diagnosed with Coronavirus?

In the last 15 days, have you had a presumed or confirmed contact with anyone diagnosed with Coronavirus? Yes No
In the last 15 days, have you sought medical care for either of the above scenarios?

In the last 15 days, have you sought medical care for either of the above scenarios? Yes No
If you have experienced either of the scenarios above (in the last 15 days), have you come in contact with classmates, coworkers, or other members of the IVC campus community?

If you have experienced either of the scenarios above (in the last 15 days), have you come in contact with classmates, coworkers, or other members of the IVC campus community? Yes No
Acknowledgements

Acknowledgements I hereby certify that the responses provided above are accurate and honest to the best of my knowledge. I acknowledge that my temperature will be checked at the campus screening station. I understand that access to campus will be denied when my temperature is above 100.4 degrees Fahrenheit.
IVC Staff Only

This would only be filled out in certain situations so you may ignore it unless you are asked to fill it in.
Name of Pre-Screening Staff Member Assisting You: Name of Pre-Screening Staff Member Assisting You: First Last

General COVID-19 Pre-Screening Form v4

General COVID-19 Pre-Screening Form v4

Visit Information

Vaccination Assessment

Symptom & Exposure Assessment

IVC Staff Only