Revised May 11, 2020
Campus Access COVID-19 Screening
Black River Technical College
The health of those who come on campus is important to us. Please complete all questions.
1. Within the last 14 days, have you traveled internationally, taken a
cruise, or traveled to areas within the U.S. with widespread COVID-
19 cases or designated hot spots by the CDC or Arkansas Governor?
2. Within the last 14 days, have you had close contact (6 feet or less)
with or cared for someone who is suspected or confirmed to have
3. Have you been diagnosed with or do you believe yourself to have
4. Do you currently have a fever greater than 100.4 F or have you
experienced such a fever within the last 72 hours?
5. Have you felt unwell within the last 72 hours with respiratory
symptoms (cough, high temperature, shortness of breath, difficulty
breathing) that you cannot attribute to another health condition?
Date: _______________ Name: _________________________________________________
Current temperature: ___________ Reason for visiting: ______________________________
If you answered Yes to any of these questions or you have fever, we ask that you leave campus
until you are fever-free for 72 hours, until 7 days since you had other symptoms, or until a
quarantine period of 14 days has elapsed in the case of contact, diagnosis, or travel.
If you answered No to all questions, current recommendations for disinfection and social
distancing are mandatory. You may be asked to leave if you do not follow these restrictions:
1. Wash your hands thoroughly following CDC guidelines.
2. Remain at least 6 feet away from other persons at all times.
3. Stay in the area you are approved to access.
4. Do not wander around campus.
5. Congregate in groups appropriate to the current Phase of the Return to Campus Plan.
Fewer is preferable.
If a direct supervisor, security officer, or physical plant personnel asks you to leave a BRTC
facility, please be understanding and leave the building immediately.