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Navarro College - Pre-Screening Questionnaire
You must complete this form to be screened for eligibility to come on campus. This form needs to be completed for each day you intend to be on campus. Forms may be filled out up to 2 days in advance but no later than 1 hour prior to arrival on campus (your program may set earlier deadlines).
Please select your status
Student
Faculty/Staff
Visitor
TAMUC
Tarleton
Name
First Name
Last Name
Student/Employee ID Number
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Accompanying Persons - If there will be an additional person with you (such as a family member), please list their name. They will also need to complete a pre-screening form.
Enter accompanying person
Date you will be on campus
-
Month
-
Day
Year
Date
Activities being performed - Please describe what you will be doing on campus. Be sure to add which building(s) you will be going to. ·
Screening Questions
Think of the last 14 days when answering the following questions.
Have you tested positive for COVID-19 or are you awaiting results from a COVID-19 test? (If testing was done solely out of precaution or required for facility entrance such as hospital, nursing home, etc., you may answer this question “no”.
Yes
No
Are you feeling sick? Based on Guidance provided by State health authorities check yes if you are experiencing new or worsening symptoms of the following: Cough, Shortness of breath or difficulty breathing, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, Loss of taste or smell, Diarrhea, Feeling feverish or a measured temperature greater than or equal to 100.0 degrees Fahrenheit. ·
Yes
No
Are you in a home with, or have been in close contact with someone who is sick? Based on Guidance provided by State health authorities check yes if you came within 6 feet or exposed to cough/sneeze from someone with confirmed COVID-19.
Yes
No
Have you received all required doses for a COVID-19 vaccine?
Yes
No
Acknowledgements
In accordance with Navarro College policy regarding face coverings, I am prepared to wear my personal face covering while on campus.
I acknowledge
The college has compiled information from various sources, including information on appropriate cleaning and disinfection, hand hygiene, and respiratory etiquette. This information can be found at: https://www.navarrocollege.edu/covid-19/ ·
I acknowledge
Submit
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