Self-Health Screen Acknowledgement Form
I understand a self-health screen and must confirm the below prior
to coming on MCC property.
Currently or in the past fourteen (14) days I have not:
1. Had a fever of 100.4° F or higher
2. Had a cough
3. Experienced shortness of breath or difficulty breathing
If at any point I develop any of the above symptoms or believe that I have been exposed to COVID-19 I
will no longer come in person to MCC for work or classes and will properly notify MCC as detailed below.
If I am a student I will not return to campus until I have provided the Dean of Students with:
1. A physician’s note stating I do not pose an ongoing safety risk
If I am an employee I will not return to campus until I have provided Human Resources with:
1. A physician’s note stating I do not pose an ongoing safety risk
If I am a non-student/non-employee I will notify my point of contact and not return and/or come on MCC
property until it has been approved by MCC.
Failure to follow these guidelines creates a health and safety risk to you and your fellow MCC students
and instructors. If you have any questions regarding COVID-19 including symptoms or screening questions
please refer to the CDC
.
Printed Name: Date:
Signature:
