Visit to Campus Screening

Screening Questions

Individuals must take their temperature prior to arriving on campus. The CDC currently recommends that if an individual has a temperature of 100.4 degrees or higher, they should not leave home.

I agree to take my temperature prior to arriving on the Wittenberg University campus.

Yes

No

Have you been evaluated for COVID-19 exposure?

No

Yes but it was negative

Yes and it was positive

Date of COVID-19 Test:

Within the last two weeks, have you experienced cough, fever, or shortness of breath, or any other symptoms described by the CDC?

Yes

No

Close contact as used below is defined as being within approximately 6 feet (2 meters) of another person for a period of time; close contact can occur while caring for, living with, visiting, or traveling with others or being in a confined space with others. It can also include being coughed on or sneezed on or sharing bodily fluids with another person.

Have you been in close contact with someone who have been evaluated for COVID-19 exposure within the last two weeks?

No

Yes but it was negative

Yes and it was positive

Within the last two weeks, have you been in close contact with someone who was (within the last month) or is currently experiencing cough, fever, or shortness of breath, or any other symptoms described by the CDC??

Yes

No

Have you traveled outside of your home state or outside the United States within the last two weeks?

Yes

No

Please list all states and/or countries to which you have traveled.

Have you had close contact to anyone who has traveled outside of your home state?

Yes

No

If outside of Ohio and/or the United States, please list the states and/or countries.

By checking this box, I certify that the above information is true and accurate to the best of my knowledge at this time. I further agree not to hold Wittenberg University or any of its employees, contractors, or students liable for acts of negligence regarding my health or the health of anyone associated with the University with whom I may come in contact during my visit. Additionally, I agree to wear a mask while on campus. Should my health status change between now and the time of my visit, I will alert the University immediately and reschule my visit.

I agree

Signature Box:

Date: