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 accurately and completely fill-out and submit the form for each day that you need to visit campus. The Enhanced COVID-19 Screening Tool can assist you in responding accurately and completely to the Screening Criteria on this form. Lake Land College staff are unable to advise individuals on how to complete the screening criteria. When in doubt, err on the side of caution.

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 (See The Enhanced COVID-19 Screening Tool for assistance with completing this form.)

I am not presently under an isolation or quarantine protocol by a public health department related to COVID-19, or a Virtual Access Only restriction by Lake Land College.

Within the last 14 days, I have not tested positive for COVID-19, or I have tested positive and been released by a public health department, and do not suspect I currently have COVID-19.

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 had close contact with someone who tested positive for or is suspected of having COVID-19. The CDC defines a "close contact" as:
- You were within 6 feet of someone who has COVID-19 for a total of 15 minutes or more
- You provided care at home to someone who is sick with COVID-19
- You had direct physical contact with the person (hugged or kissed them)
- You shared eating or drinking utensils
- They sneezed, coughed, or somehow got respiratory droplets on you
Specific Information For Healthcare Workers and Clinical Students
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.

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.I further agree that I have followed all guidance provided in The Enhanced COVID-19 Screening Tool in the completion of this self-screening form.

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