Mercyhurst University

      COVID-19 Guest Screening Form

       
      Resilence and Resolve

      Guest Screening

      Mercyhurst University's campuses are private property. Unless you are a current student, employee, or authorized contractor, you are not permitted in any campus building or facility without explicit permission and consent from Mercyhurst. Complete this form to seek permission.

      Visitors must be approved before entering campus.  All visitors must wear a mask that covers your mouth and nose at all times (indoors and outdoors) and practice social distancing by remaining six feet away from others whenever possible.

      Your responses on this form will be used to determine if you are permitted on campus.  If you are permitted, messages authorizing your temporary presence will be texted and emailed to you. Save these authorization messages — you may be asked by a Mercyhurst official to show proof of permission.  

      If you are accompanied by others, all members of your group must individually complete this form.

      About You

      About Your Visit

      Screening Questionnaire

      According to the U.S. Centers for Disease Control, COVID-19 symptoms can include:
      • Shortness of breath
      • Cough
      • Fever (especially 100.4 F or greater)
      • Chills 
      • Muscle or body aches
      • Headache
      • Sore throat
      • New loss of taste or smell


      Are you currently experiencing any of the COVID-19 related symptoms noted above?


      Are you currently experiencing any of the COVID-19 related symptoms noted above?


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


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


      Have you been in contact with anyone known or suspected to have tested positive for COVID-19 in the last 14 days?


      Have you been in contact with anyone known or suspected to have tested positive for COVID-19 in the last 14 days?


      In the past 14 days have you traveled to a state designated as a "hotspot" by Pennsylvania or traveled internationally?


      In the past 14 days have you traveled to a state designated as a "hotspot" by Pennsylvania or traveled internationally?


      Do you understand that Mercyhurst University cannot be held liable for any exposure to the COVID-19 virus?


      Do you understand that Mercyhurst University cannot be held liable for any exposure to the COVID-19 virus?

      ATTESTATION & SIGNATURE

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