This form should be submitted prior to arriving at JRC.
First Name:
Last Name:
Email:
Phone#:
If visiting a Student/Client please list their name(s):
Today or in the past 24 hours, have you had any of the following symptoms in a way not normal to you: fever (temp. of 100.0°F or abov, felt feverish or alternating sweats and chills or shaking, cough, shortness of breath, difficulty breathing, rapid breathing, sore throat, fatigue, gastrointestinal symptoms (diarrhea, nausea, vomiting, abdominal pain), unexplained rash, headache, flushed cheeks, new nasal congestion or new runny nose, new loss of smell or taste, new muscle or body pain/aches, or any other sign of illness? (While other illnesses may not be COVID-19, they may facilitate the transmission of the virus.) Any visitors with COVID-19 symptoms will not be permitted to enter.
Have you taken medicine within the last 24 hours to lower a fever?
Have you or anyone in your household had close contact with someone in the previous 5 days with a confirmed or presumptive diagnosis of COVID-19? Visitors with exposure to SARS-COV2 during the last 6-10 days may only enter if they do not have any COVID-19 symptoms and are able to wear a facemask at all times.
Have you tested positive or been diagnosed with COVID-19 within the past 5 days or are you waiting to receive the results of a COVID-19 test? Visitors who have tested positive or been diagnosed with COVID-19 during the last 6-10 days may only enter if they do not have any COVID-19 symptoms and are able to wear a facemask at all times.
Are you currently required to quarantine or to be in isolation following a request or direction made by a health care provider or a local public health official?
Have you or anyone in your household traveled internationally in the past 5 days to countries with widespread, sustained community transmission?
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All questions must be answered before submitting