COVID-19: Employee/Student/Guest/Vendor/Visitor Screening Questions and Guidelines

• *First Name:
• *Last Name:
• *Student or Employee ID (if known):
• *Phone Number:
• *Email Address:
• *Relationship to Campus: Employee
  Student
  Guest/Visitor
  Vendor
  
  
• *Reason for visit to campus today: Continuing Education Class:
  
  Other (appointment, services, visit)
  
  
  

*Have you had any of these symptoms in the last 14 days?

Fever (>100.4 F) (Uncontrollable chills or sweating)

Shortness of breath

Cough

Flu Like Symptoms (nausea, body aches, headache, sore throat)

No, I have not had any symptoms in the last 24 hours.

• *Have you or someone you are caring for tested positive for COVID-19? Yes  No
  
  
• *Are you ill, or caring for someone who is ill? Yes  No
  
  
• *Have you had contact with anyone with confirmed COVID-19 in the last 14 days? Yes  No
  
  

Please review and sign the consent statement below.

• *I have agreed to the above stated screening for COVID-19 related health information. I understand that this information will be considered protected health information and will be maintained in a confidential medical file and stored in the EICC Human Resources Office.

It is the policy of Eastern Iowa Community College District not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, and actual or potential family, parental or marital status, as required by the Iowa Code §§216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681-1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact EICC’s Equal Employment Opportunity Officer/Equity Coordinator, Eastern Iowa Community College District, 101 West Third Street, Davenport, Iowa 52801, 563-336-5222, equity@eicc.edu or the Director of the Office for Civil Rights U.S. Department of Education, John C. Kluczynski Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560 Facsimile: (312) 730- 1576, TDD (800) 877-8339 OCR.Chicago@ed.gov.