Health Screening Questionnaire

As concerns over the COVID-19 coronavirus continue to remain high, Inland is initiating a new temporary process to enter any campus building for all employees and visitors in an effort to reduce the risk of exposure.

Please complete and sign the screening questionnaire below prior to entering the building. Please note that if the answer to any of the first three questions is "yes", you will not be allowed to enter any of the buildings and will be given additional instructions.

Name is required.
Valid Email id is required.
Mobile Number is required.
"Inland Entity Employed By / Visiting" is required.
"Inland Employee Visiting" is required.
"Building" is required.
"Floor" is required.

Have you or household members returned from international travel or from states (select from dropdown) experiencing a surge in COVID-19 cases within the last 14 days?

Have you or household members received a positive result from a COVID-19 test, had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

Have you or household members experienced any cold or flu-like symptoms in the last 14 days (fever of 100.4 ℉ or greater, cough, sore throat, respiratory illness, difficulty breathing, shortness of breath, gastrointestinal concerns, fatigue, headache or new loss of taste or smell)?

When you took your temperature at home this morning, was it 100.4 ℉ or greater?

- VISITORS MUST ALWAYS WEAR A MASK AT ALL TIMES WHILE ON CAMPUS -

By signing this questionnaire, you acknowledge your awareness and acceptance of the risks associated with the COVID-19 outbreak in the United States, including at the Inland campus. You also specifically acknowledge and understand that: (1) you and all others on the Inland campus will be expected to follow and comply with all safety protocols implemented by Inland such as wearing a mask at all times while on campus, social distancing, and proper hygiene measures; and (2) you will monitor your personal symptoms and temperature daily and will complete a Health Screening Questionnaire each day you are on the Inland campus.

Signature is required.
Date is required.