Editing previous response:

Please fix the highlighted areas below before submitting.

Non-TSD Staff Self Screening Form

Please complete the form below. Required fields marked with an asterisk *

Non-TSD Staff Self Screening Form

This form must be completed prior to entering the TSD campus. You must complete it each time you come to campus.

Name*

Answer Required

Phone Number*

Number Required

Company Name

Answer Required

Date*

Answer Required

Time arriving on campus*

Answer Required

Person requesting the work or service*

Answer Required

Buildings or areas you are working in or visiting*

Answer Required

Have you experienced any of the following symptoms in the past 48 hours: • 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*

Answer Required

Yes

Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19?*

Answer Required

Yes

Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who has any symptoms consistent with COVID-19?*

Answer Required

Yes

Conclusion

If you answered Yes to any of the 3 questions above you are not permitted to enter the TSD campus, and must remain symptom free for 14 days prior to returning to campus. Thank you for your cooperation in keeping our students, staff, and campus safe.