CCSF Building Entry Form

Name

Student/Employee ID

Today's Date

CCSF Work/Student Email

Phone number

Building Entry

Are you a Student or Employee?

By checking this box, I understand that I am responsible for filling out this survey every day that I enter a CCSF building.

By checking this box, I acknowledge that I do NOT have any of the following symptoms:

Have you tested positive for COVID-19 in the past 10 days?

Have you been exposed to anybody that has tested positive for COVID-19 in the past 10 days?

Are you fully vaccinated against COVID-19?

By checking this box, I certify that I am entering this building to attend a class or meet with a college employee.

By checking this box, I agree to the following:

If I feel that I am unwell, I understand I should not come to any CCSF locations for any reason.
If my symptoms get worse, I should contact my primary care physician.
If I'm diagnosed with COVID-19/Corona Virus, I will immediately report it to my instructor for contact tracing purposes.

By checking this box, I certify that I am entering this building for work purposes and have been approved by my supervisor to do so.

By checking this box, I certify that I am entering this building to conduct business with CCSF.

By checking this box, I agree to the following:

If I feel that I am unwell, I understand I should not come to any CCSF locations for any reason.
If my symptoms get worse, I should contact my primary care physician.
If I'm diagnosed with COVID-19/Corona Virus, I will immediately report it to my supervisor for contact tracing purposes.

By signing below, I acknowledge that I have answered these questions truthfully and responsibly pertaining to my current state of health.

I will wear a face covering at all times, will maintain safe social distancing, and agree to abide by the CCSF Return-to-Campus rules and training.

Sign Here

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