COVID-19 Campus Visit Screening Form

COVID-19 Campus Visit Screening

In response to the COVID-19 pandemic and in order to ensure a safe and healthy environment for our campus community, guidance from the Illinois Community College Board and the Illinois Board of Higher Education provides that visitor health screenings may be on a self-monitoring basis. All students, employees and visitors must complete a daily self-screening prior to visiting campus. Lake Land College reserves the right to prohibit an individual from entering College property based on the results of the self-screening.

Please complete and submit this form each day that you need to visit campus.

When visiting a campus location, you MUST wear a face mask that covers both your nose and mouth and maintain social distancing of six feet, per the CDC guidelines.

Date of Requested Visit *

First Name *

Last Name *

Email *

I am a *
Student Faculty/Staff Visitor

Student or Faculty/Staff ID (optional)
You may be asked to present your student or faculty/staff ID upon arrival to campus

Screening Criteria

I am not experiencing any known symptoms of COVID-19, including: a fever (100.4 or higher), cough, shortness of breath or difficulty breathing, chills, fatigue, muscle or body aches, headache, sore throat, new loss of taste or smell, congestion or runny nose, nausea, vomiting, diarrhea, or any other COVID-19 symptoms identified by the Centers for Disease Control (CDC) or the Illinois Department of Public Health (IDPH).

Within the last 14 days, I have not tested positive for COVID-19 and do not suspect I have COVID-19.

Within the last 14 days, I have not had close contact with someone who has tested positive for or is suspected of having COVID-19. For COVID-19, the CDC defines a "close contact" as "any individual who was within 6 feet of an infected person for at least 15 minutes 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."

If within the last 14 days a member of my household has had "close contact" with someone who tested positive for COVID-19, the household member is not experiencing symptoms of COVID-19 or has not tested positive for COVID-19.

Within the last 14 days, I have not traveled internationally.

I am not presently under an isolation or quarantine protocol related to COVID-19.

Self-Monitoring of Screening Criteria: (select one response)
I verify and certify that I meet all of the above screening criteria at this time.
I am UNABLE to verify that I meet all of the above screening criteria at this time.

By submitting this form, I agree to abide by all guidance outlined in the Lake Land College Return to Campus Plan while at a Lake Land College location and acknowledge the risks associated with entering a Lake Land College facility related to COVID-19 and other communicable diseases.

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