COVID-19 Campus Visit Screening Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pick the Date of Visit
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pick the Time of Visit
Hour Minutes
AM
PM
AM/PM Option
Duration of Visit (hours)
Reason(s)/Purpose for Visit
Are you a student?
Yes
No
Student Number/Code
Are you a Faculty Member/Staff?
Yes
No
Name of Department
Are you a prospective student?
Yes
No
Current Grade Level
Are you a guest?
Yes
No
Age
Is this your first time to Visit The Campus?
Yes
No
Name of the Person to Visit
First Name
Last Name
Department
Building Name
Floor Level
Office Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please answer the following:
Have you been tested positive for COVID 19 within the last 14 days?
Yes
No
Do you have any travel history within the last 7-14 days?
Yes
No
Out of State travel or International travel?
Out of State
International
Have you been in close contact or proximity to someone who’s been tested positive for COVID 19 within the last 14 days?
Yes
No
Are you currently waiting for a COVID 19 test result within the last 7-14 days?
Yes
No
Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: