Emmaus 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.
Accedi a Google per salvare i risultati raggiunti. Scopri di più
Email *
Name *
Hometown and State *
Reason for Visiting
Cancella selezione
Your Current Temperature *
Please take an accurate current temperature using a digital thermometer within 24 hours of traveling to Emmaus.
Have you had close contact or cared for an individual who has tested positive for COVID-19 in the past 14 days? *
If Yes, please explain
Have you had positive test in the last 14 days?
Cancella selezione
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.
Obbligatorio
If experiencing symptoms, please explain
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. (See your host for more information.)
Invia
Cancella modulo
Non inviare mai le password tramite Moduli Google.
Questo modulo è stato creato all'interno di Emmaus Bible College. Segnala abuso
Google Moduli