Employee Health Check – COVID-19 Safety

Last Name*

First Name*

A#*

Please enter your Mt. SAC Staff/ Faculty Number.

Email Address:*

Mt. SAC email preferred.

Phone Number:*

Phone

Preferred Method of Contact*

Phone

Administrative Services Department*

Select

Administrative Services Manager Names*

Select

Instruction Department*

Select

Instruction Managers*

Select

Human Resources Department*

Human Resources - Division

Human Resources Managers*

Select

Office of the President Department*

Select

Office of the President Managers*

Select

SCE Managers*

Select

Student Services Department*

Select

Student Services Managers*

Select

Date Coming to Campus*

Screening Guidelines

1. If you are having any signs of COVID-19 please STAY HOME. 2. Please complete the below Screening Guideline is for Instructors and staff when you are having possible symptoms of COVID-19. 3. Instructors and Staff with one or more of these signs or symptoms are considered to have a communicable illness and need to contact their medical provider and contact tracing line immediately 909-274-6900. 4. Instructors and Staff will not be allowed to return to campus until cleared by a Medical Professional or Contact Tracing team in Human Resources.

Have you tested positive for COVID-19 in the past 14 days?*

Yes

If yes, please select the date you tested positive.*

Have you or anyone in your home been instructed by a healthcare provider or public health official to self-isolate or self-quarantine in the past 14 days?*

Yes

If yes, who was instructed to self-isolate or self-quarantine?*

Someone In My Home

If “someone in my home,” Do they have symptoms or have they tested positive for COVID-19?*

Yes, Symptoms OR Tested Positive for COVID-19

In the last 14 days, have you been in close contact with a person who is a confirmed positive COVID-19 case (within 6 feet for more than 15 minutes)?*

Yes

Are you experiencing influenza or COVID-19 like symptoms?*

Yes

If yes, please select all the symptoms you are experiencing:*

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