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 five questions is "yes", unless you are fully vaccinated, you will not be allowed to enter any of the buildings and will be given additional instructions.

Select Status
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.

Are you Fully Vaccinated? Fully Vaccinated means that it has been at least two weeks since you received:
1) your second dose of the Pfizer/BioNTech or Moderna COVID-19 vaccine; OR
2) your single dose of the Johnson & Johnson COVID-19 vaccine.

For Inland Employees Only: please email your CDC provided card showing vaccination proof to HR-Covid-Vaccine@inlandgroup.com.You only need to send your COVID-19 vaccination card once to this email address. Please do not send any additional medical or family history information along with your card
Proof of your vaccination will be kept confidential in accordance with the ADA

OR

Have you or household members returned from international travel or to states (select from dropdown) within the last 10 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 10 days?

Are you or any members in your household currently waiting on the results of a COVID-19 test due to potential exposure and/or COVID-19 like symptoms?

Have you or household members experienced any COVID-19 symptoms in the last 10 days (fever of 100.4 ℉ or greater, cough, sore throat, respiratory illness, difficulty breathing, shortness of breath, gastrointestinal concerns or new loss of taste or smell)?

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

Are you or any family members currently experiencing any COVID-19 symptoms (fever of 100.4 °F or greater, cough, sore throat, respiratory illness, difficulty breathing, shortness of breath, gastrointestinal concerns 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.