Visitor Health Screening Questionnaire

In an effort to reduce the risk of COVID-19 exposure to Hollins University employees and students, all visitors must complete the following screening questions.

Today's date

Student's First Name

Student's Last Name

Birthdate

Please list all guests that will be joining you during the campus tour.

Have you and all guests accompanying you today been vaccinated against COVID-19?

Yes

No

Have you, or anyone traveling with you to campus, traveled outside of the United States or outside your normal, daily routine, or have you been in close contact with anyone who has similarly traveled within the last 14 days?

Yes

No

Have you or any of your guests been in close contact with or cared for someone diagnosed with COVID-19 within the last 14 days or who has symptoms compatible with COVID-19?

Yes

No

Do you or any of your guests have new or worsening onset of any of the following symptoms: fever, cough, shortness of breath, runny nose, sore throat, chills, body aches, fatigue, headache, loss of taste/smell, eye drainage, congestion?

Yes

No

On behalf of myself and my guests, I agree to take responsibility for my own health and for those around me by helping mitigate the spread of COVID-19 and other infectious illnesses. I agree to abide by Hollins University’s Culture of Care which includes wearing an appropriate face mask and remaining physically distanced (6 feet) during my time on campus.

Yes

No