Pre visit Health Screening

General Pre-visit health screening

Required

Please complete this form in its entirety prior to your campus visit. The form must be completed individually for each member in your party.

Name of department you will be visiting:required
I am asymptomatic of any illness (cough, fever, sore throat, etc.)required
Is your temperature under 100 degrees?required

Have you:

In the past 24 hours: (Check all that apply)required
Please select up to 5 choices
Are you fully vaccinated against Coved-19?required
Electronic Signaturerequired
By selecting yes for Electronic Signature; I am indicating my signature. I am also agreeing that the information above is true, and I will adhere to the Country Day visitor policy.