COVID-19 Health Pre-Screening Form

For the safety of our students and associates ANYONE entering a KCC campus WILL BE screened for COVID related symptoms and temperature checked prior to entry ON A DAILY BASIS.

ANYONE EXHIBITING COVID SYMPTOMS WILL BE DENIED ENTRY.

To help expedite the screening process, individuals can pre-screen prior to their arrival. Pre-screening must be completed daily between midnight and 7a to provide for expedited campus entry for the day.

Campus Access Date
(Note: Date resets at midnight each day. Entry Only valid for one day. You can not change this date.)
Campus Access Date
(Note: Date resets at midnight each day. Entry Only valid for one day. You can not change this date.)
/ MM / DD YYYY
I am a:
Contact Email
Student, KCC Associate or Visitor Name Student, KCC Associate or Visitor Name First Last
Campus
Does the individual being pre-screened currently have any of the following symptoms (check all that apply)?

Does the individual being pre-screened currently have any of the following symptoms (check all that apply)? Fever (99.5°F or higher), or a sense of having a fever. New cough that cannot be attributed to another health condition. New shortness of breath that cannot be attributed to another health condition. New sore throat that cannot be attributed to another health condition. New muscle aches that you cannot attribute to another health condition, or that may have been caused by a specific activity (such as physical exercise). Loss of taste or smell.
Has the individual being pre-screened or anyone in their home had contact within the last fourteen days with any person under screening/testing for COVID-19?

Has the individual being pre-screened or anyone in their home had contact within the last fourteen days with any person under screening/testing for COVID-19? Yes No
Has the individual being pre-screened had contact within the last fourteen days with anyone with known or suspected COVID-19?

Has the individual being pre-screened had contact within the last fourteen days with anyone with known or suspected COVID-19? Yes No
Body Temperature 99.5F or Higher?

Body Temperature 99.5F or Higher? No Yes
Recorded Temperature

Record your temperature here.
Is the individual being pre-screened experiencing any Respiratory Symptoms such as trouble breathing, persistent pain or pressure in the chest or coughing?

Is the individual being pre-screened experiencing any Respiratory Symptoms such as trouble breathing, persistent pain or pressure in the chest or coughing? No Yes
Screening completed by Name Screening completed by Name First Last
For the safety of our students and associates, you ARE NOT permitted to be on campus. PLEASE STAY HOME.

YOU WILL BE CONTACTED WITH FURTHER INSTRUCTIONS AT THE EMAIL YOU PROVIDED.
Date Student or Associate Denied Entry Date Student or Associate Denied Entry / MM / DD YYYY
Notification Required!

Notification Required! You must check here to notify Campus Director of findings.
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7, 8, 9, 10 : the 3rd number is?

COVID-19 Health Pre-Screening Form

COVID-19 Health Pre-Screening Form

For the safety of our students and associates, you ARE NOT permitted to be on campus. PLEASE STAY HOME. YOU WILL BE CONTACTED WITH FURTHER INSTRUCTIONS AT THE EMAIL YOU PROVIDED.

For the safety of our students and associates, you ARE NOT permitted to be on campus. PLEASE STAY HOME.

YOU WILL BE CONTACTED WITH FURTHER INSTRUCTIONS AT THE EMAIL YOU PROVIDED.