Visitor Check-in Form / Formulario de registro de visitante (English)

Clackamas ESD places the highest priority on the health and safety of its visitors and staff members. Before entering the building, please take a few minutes to complete this form. We appreciate your cooperation. Si necesita acceder a este formulario en español, haga clic en esta URL: https://app.smartsheet.com/b/form/8d12b1cdc0e240b0aa63b2d445086077

Location*

Please indicate which CESD Facility you are visiting today.

Select

First Name*

Last Name*

Company / Agency / District / Patron*

Where are you from, or are you a member of a family we serve?

Preferred Contact Method*

Please provide the best way for us to reach you if we need to follow up after your visit.

Select or enter value

Phone Number

Purpose for Visit*

Select

Name of primary contact during visit

Are you fully vaccinated against COVID-19?

This question is optional. If you choose not to answer, then you will be considered unvaccinated for determining next steps for contact tracing purposes.

Select

Temperature*

Have you experienced any of the following symptoms (not attributable to a previously known condition) in the past 48 hours?*

Please check all that apply.

Select

Symptom Details

Please provide any additional details regarding reported symptoms.

Additional Screening Required

Please complete the survey by clicking the submit button, notify the front desk attendant, exit the building and wait for a staff member to contact you for additional screening.

Attestation*

Checking the box below and submission of this document contstitutes my electronic signature that at the time and date of submission the COVID 19 health screening is true and correct to the best of my knowledge and by submitting this form, I consent for health screenings including temperature taking. By electronically submitting this document, you are authorizing Clackamas ESD staff to verify your COVID 19 health screening responses each time you arrive on campus. You also understand should you have symptoms that indicate a risk of coronavirus infection, you should not proceed to any Clackamas ESD location. Once at a CESD location and upon verification if symptoms are displayed you may be sent away with OHA instructions/recommendations. If you display symptoms, you must follow OHA guidelines before returning.

Liability Waiver*

By checking this box, I acknowledge I have read, have received a copy, and agree to the terms of the VISITOR/GUEST ASSUMPTION OF RISK, WAIVER OF LIABILITY, AND COVID-19/COMMUNICABLE DISEASE AGREEMENT

Send me a copy of my responses

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