COVID-19 Screening Form
COVID-19 Screening Form
Please complete and submit on the day you plan to enter a building at HCC.
If you have an HCC ID card, you must provide your ID card number - failure to do so may delay or prevent access to campus.
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= Required Field.
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Role at HCC
-- select role --
Student
Faculty/Staff
Visitor
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First Name
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Last Name
HCC ID Card Number
(the number on the front of the card - include the "H")
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Email Address
Building Visited
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1. Have you or someone in your household been in close contact
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with a confirmed case of COVID-19 within the past 10 days?
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For COVID-19, public health officials define close contact as any individual who was within 6 feet of an infected person for a total of 15 minutes or more over a 24 hour period starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to positive specimen collection) until the time the patient is isolated.
No
Yes
*
2. Have you or someone in your household had a fever or felt feverish in the last 72 hours?
No
Yes
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3. Are you or someone in your household experiencing any new respiratory symptoms including a runny nose, sore throat, cough, or shortness of breath?
No
Yes
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4. Are you or someone in your household experiencing any new muscle aches or chills?
No
Yes
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5. Have you or someone in your household experienced any new change in your sense of taste or smell?
No
Yes
