COVID-19 Employee and Student Screening Form

Georgian Court University is committed to the health and safety of everyone on our campus. The university is operating with strict public health precautions in place, a range of screening activities, and enhanced disinfection procedures.

All students and employees on campus must wear a mask or facial covering when indoors and practice social distancing by remaining six feet away from others whenever possible.

Georgian Court University’s facilities are private property. Unless you are a current student, employee, or authorized contractor, you are not permitted in any campus building or facility without explicit permission and consent from Georgian Court University. Complete this form to seek permission.

Your responses on this form will be used to determine if you are permitted on campus. If you are permitted, messages authorizing your temporary presence will be texted and emailed to you. Save these authorization messages — you may be asked by a GCU official to show proof of permission.

If you are accompanied by others, all members of your group must individually complete this form.

Your information will be used only for the purpose of screening guests to the GCU campus. Thank you in advance for helping us ensure your personal wellness and the health of others. We appreciate it.

First Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Mobile Phone

Email Address

During the past 30 days, have you had direct contact with anyone that you know has been diagnosed with COVID-19 or is presumed to have COVID-19? (If you are using your personal protective equipment properly, employing appropriate hand hygiene, and following other safety measures for health care workers, you may answer “NO” to this question. However, if you have had contact with an individual with known or possible COVID-19 outside work, without you using your personal protective equipment properly, employing appropriate hand hygiene, and following safety measures for health care workers, you should answer “YES")

Have you had a fever the past 7 days?

Do you have a fever (over 100F) TODAY?

Have you had any of the following symptoms in the past 7 days?

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

Do you have a history of the symptom/s?

Are you under a doctor’s care for the symptoms?

Have you had a positive-COVID test for active virus in the past 14 days?

Do you understand that Georgian Court University cannot be held liable for any exposure to the COVID-19 virus?

If you are a student and have any questions about your specific situation, please contact Health Services at 732-987-2756 or healthservices@georgian.edu. If you are an employee, please contact Janice Karluk in Human Resources at jkarluk@georgian.edu.

ATTESTATION & SIGNATURE

In place of a physical signature, type your full name in the "Electronic Signature" box below, attesting to the following statement:

"I attest that, to the best of my knowledge, the information I provided above is accurate, honest, and complete."

We consider your typed signature and submission of this form to be a legal record of your attestation. In addition to your form responses, your IP address and details about your device are captured to preserve documentation of your attestation.

Electronic Signature:

Date

COVID-19 Employee and Student Screening Form

ATTESTATION & SIGNATURE

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