Wufoo
KSC VISITOR* COVID-19 HEALTH SCREENING ATTESTATION
Pursuant to the State of New Hampshire Universal Guidelines, everyone visiting Keene State College is required to attest to their current health for COVID-19 related symptoms prior to or just before the purpose of their visit. This health screening includes mandatory questions to answer that must be recorded as well as documenting body temperature prior to the purpose of their visit.
You must complete a health screening form every day when visiting the campus or any faculty, staff or student until further notice. Meet your point of contract (POC) at the Wyman Way Visitor Parking Lot or other agreed upon location to complete attestation if not done so beforehand.
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I attest (acknowledge or certify) that prior to the purpose of my visit.
• I am not subject to a medical advisory or other guidance to self-quarantine.
• I have not been in close contact with a person with a confirmed case of COVID-19.*
• I have not had a temperature of 100.0 degrees Fahrenheit or above and have not felt feverish in the last 72 hours. You must take your temperature within 90 minutes of arrival.
• I have not experienced any respiratory symptoms including a runny nose, sore throat, cough, or shortness of breath.
• I have not experienced any new muscle aches or chills.
• I have not experienced any new change in my sense of taste or smell.
• I have and will properly wear a cloth face mask (which meets the CDC Requirements), will maintain at least six feet from others, will wash with soap and water frequently, and comply with POC directions)
If you are sick, have one or more of the above symptoms (even mild symptoms), have had a fever above 100.0 degrees Fahrenheit or felt feverish in the last 72 hours, have been in close contact with a confirmed case of COVID-19,* or tested positive for COVID-19:
• You cannot conduct business or complete the purpose of your visit at KSC.
• Contact your POC to reschedule
• Consult your primary care provider about COVID-19 testing, or seek testing through a public testing
option, such as a State-run testing center, or local health department.
• Follow the guidance on the KSC COVID-19 Information and College Updates on COVID-19 webpage.
* Close contact for personnel working in the line of duty (e.g. EMTs, nurses, doctors, police and fire), following occupational safety and health protocols, using required personal protective equipment (such as properly fittested respirators/N95 and disposable PPE), and decontamination procedures is excepted.
By completing the following fields you are attesting (acknowledging or certifying) to this full health screening:
First and last name
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Your Company or affiliation
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First and last name of your point of contact (POC)
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POC phone number
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POC email
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Which buildings will you be entering today?
Today's Date
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