COVID-19 Visitor Questionnaire Form Name First Last Name of person/office you are visiting and whyAre you vaccinated against COVID-19? Yes No - Non-vaccinated persons are not permitted to be on campus at this time. Please leave immediately. Have you experienced a fever of 100.4 degrees or greater in the past 14 days? Yes - please leave Wesley’s campus immediately. Do not interact with any students, faculty, or staff on Wesley’s campus. Plan to return when you no longer have a fever. You may want to consider taking a COVID-19 test. No Have you received a positive result from a COVID test within the past 14 days? Yes - please leave Wesley’s campus immediately. Do not interact with any students, faculty, or staff on Wesley’s campus, and either seek further medical attention if necessary or quarantine in your home for at least 10 days after your positive test. No In the past 14 days, have you or someone you have been in close contact with traveled to an area that required quarantine upon return? Yes - no matter your vaccination status, it is advised that you take a COVID-19 test 3-5 days after travel/contact with an individual who has traveled. If you have not taken a COVID-19 test, please leave Wesley’s campus immediately and return once you have obtained a negative COVID-19 test. If you are vaccinated and your test is positive, isolate yourself for 10 days to protect others from getting infected. No In the past 14 days, have you experienced any of these symptoms that are not attributed to another health condition: cough, loss of smell or taste, runny nose, shortness of breath, or a sore throat? Yes - please leave Wesley’s campus immediately and take a COVID-19 test. You may return to campus once you receive a negative COVID-19 test result. No How long do you intend to stay on campus?Date
