TCCS COVID19 Self Report Health Screening

ATTENTION: IF YOU ARE SICK PLEASE STAY HOME AND CALL YOUR SUPERVISOR!

Name*

First Name

Last Name

Email*

Submission Date and time*

:

Department*

Company Name (Vendor Only)

The Symptoms of COVID19 include:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Have you had any of the above symptoms in the last 10 days, that cannot be attributed to another condition?*

Yes No

Definition of A Close Contact

The Los Angeles County Department of Public Health defines a “close contact” is any of the following people who were exposed to an “infected person*” while they were infectious:

a. An individual who was within 6 feet of the infected person for a total of 15 minutes or more over a 24-hour period

b. An individual who had unprotected contact with the infected person’s body fluids and/or secretions, for example, being coughed or sneezed on, sharing utensils or saliva, or providing care without wearing appropriate protective equipment.

Have you been in close contact (as defined above) in the last 10 days who has been diagnosed with or tested positive for COVID19?*

Yes No

Visit LA County Department of Public Health for more information about COVID-19 symptoms and when to seek medical advise.

Please be advised you may need to complete additional screening before you begin work on one of the campuses we serve.

Before arriving to perform work at HMC please visit-https://hmc.formstack.com/forms/keeping_mudd_safe_visitors

Before arriving to perform work at CMC please visit the CMC Human Resources Office at 528 N. Mills

Pitzer: https://pzforms.pitzer.edu/daily-covid-screening/ (QR codes are also posted on building doors)

Please scan the code posted at entrances to KGI and complete the form before entering. https://kgi.formstack.com/forms/kgi_campus_entry_and_symptom_monitoring_vendors