Pierce College COVID-19 Access Form

Visitation Type (Required)

Student
Employee
Visitor

Birth Date (required)
YYYY-MM-DD format

Remember me on this device

Identification

Visitation Type

Full Name (Required)

Not you?

School Email (Required)

Personal Email

Phone Number (Required)
Please put number in the following format: 2539646500

Campus and Contact

Please answer the following questions to indicate where you are traveling and who you will be in contact with.

Campus (Required)

Fort Steilacoom
Puyallup
Joint Base Lewis-McChord

Department(s) Visited

Health Status Screening

Please answer the following questions to determine your health status.

Do you have any of these symptoms that are not caused by another condition? (Required)

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
Recent loss of taste or smell
Sore throat
Congestion
Nausea or vomiting
Diarrhea

Yes
No

Within the past 14 days, have you had contact with anyone that you know had COVID-19 or COVID-like symptoms? Contact is being 6 feet (2 meters) or closer for more than 15 minutes with a person, or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on). (Required)

Yes
No

Have you had a positive COVID-19 test for active virus in the past 10 days? (Required)

Yes
No

Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection? (Required)

Yes
No

Electronic Signature

By checking the boxes below and submitting this form, you are agreeing to an electronic signature and that the information provided is correct to the best of your knowledge. You are also agreeing to having completed the Return to Worksite Coronavirus Education Training Module

I have read and acknowledge the statement above.
I acknowledge that I previously completed the training module above.

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1/28/2021