COVID-19 Screening Checklist Questionnaire Header Image

COVID-19 Screening Checklist Questionnaire

Please fill out this form 48 hours prior to coming on to campus. Once completed, the form will be reviewed by your department and/ division head and you will either be given clearance to come to campus or restricted from coming onto campus. Clearance will be emailed to you once the form is approved by your department. You must complete this form for each intended visit and use your Otis College ID "One-card" to gain entry on to campus and your office suite. 

NOTE: For safety reasons, a maximum of two persons should occupy the same room space on campus simultaneously for over 30 minutes. 

Name*
My primary classification is:*
FACULTY - the Provost - Jiseon Lee Isbara
Date Of Intended Visit To Campus*
Estimated time to arrive on campus*
:  
Estimated time to leave campus*
:  

Review the following carefully.


1. Do you currently have any of the following symptoms? Select all that apply.*
2. In the last 14 days, have you had close contact with anyone with suspected or confirmed COVID-19?*
3. Have you had any close contact with someone sick with any of the above listed symptoms in the past 2 weeks?*
4. In the last 2 weeks, have you tested positive for COVID-19?*
5. In the last 2 weeks, have you traveled internationally, including to Canada or Mexico or traveled out of the Southern California region?*
As of December 30, 2020, all travelers arriving in L.A.—whether you live here or are just visiting—from outside of Southern California are required to quarantine for at least 10 days. This applies to all modes of transportation, whether by plane, car or train. When did you arrive in Los Angeles County?*
Have you quarantined according to all state and local directives?*
6. Did you selected any symptoms for question #1 or said yes to any question #2 - #5?*

DO NOT COME TO CAMPUS AT THIS TIME:

You have noted that you are either experiencing symptoms of COVID-19 or confirmed conditions that prevent you from being able to gain access to campus. Please stay at home and remain away from Otis College campus.  The college suggests that you contact your Primary Care Provider (PCP) and follow their direction as advised.

If you have any questions regarding your benefits and/or you require sick leave you may contact Pam Sasuga at psasuga@otis.edu.

Department Approval

Does the faculty/staff member above have permission to come to the College on the date and times list above?*
Use your mouse or finger to draw your signature above

Division Head Approval

Does the faculty/staff member above have permission to come to the College on the date and times list above?*
Use your mouse or finger to draw your signature above