LakeLandCollege‐AuthorizedEmployee/VisitorAccess
Level3RestrictedAccess‐DuetoCOVID‐19Pandemic.
AuthorizedEmployee/VisitorName:____________________________Position:_______________________________
AuthorizedLocation(s)onCampus:_____________________________________________________________________
ReasonforCampusAccess:
DateofAccess:____________________
(Write“ongoing”ifseekingpreauthorizationforregularvisitstothesamelocation)
LandCollegeistakingappropriatemeasurestopreventthespreadofCOVID‐19.Anemployeeorvisitorseekingaccessto
campusbuildingsduringLevel3RestrictedAccessmustanswerthequestionsbelow.Iftheindividualanswers“yes”toanyofthe
followingquestions,theywillberestrictedfromaccessingcampus.Thankyouforyourpatienceandunderstanding.
Yes No
Ihavebeeninclosephysicalcontactwithindividuals whorecently traveled toacountry orareawithinthepast14
dayswheretheUnitedStatesGovernmenthasrestrictedtravelduetotheCOVID‐19pandemic.

Ihavebeeninclosephysicalcontactwithindividuals whohavebeendiagnosedwithCOVID‐19orhavebeen
quarantinedduetoasuspectedcaseofCOVID‐19.

IhavebeendiagnosedwithCOVID‐19orhavebeenquarantinedduetoasuspectedcaseofCOVID‐19.

Ihave,orhavehadwiththepast48hours,symptomsofCOVID‐19includingafever,drycough,shortnessof
breath,orpersistentpainorpressureinmychest.

TheundersignedacknowledgesthatduringLevel3RestrictedCampus,theirvisitstocampusareonlyauthorized
forthelocation(s)specifiedabove.Additionally,theundersignedunderstandsthatanswering“yes”toanyofthe
abovequestionswillimmediatelyrestricttheiraccesstocampus.Employeesandvisitorsmustprescreen
themselvesusingtheabovereferencedquestionsbeforeanyplannedcampusvisit.Iftheprescreenelicitsa“yes”
responseforanyoftheabovequestions,theundersignedagreestorefrainfromcampusvisitsuntilallquestions
canbeanswered“no”.
Employee/VisitorSignature:_____________________________________________________________________
________________________________________________________________
APPROVALSTATUS:⃝Approved ⃝NotApproved Date:_____________________________
ApproverName:___________________________________ApproverTitle:_______________________________
ApproverSignature:____________________________________________________________________________
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