Need to complete the COVID-19 Screening Questionnaire? Here is the form for students and employees and the form for visitors and contractors.
If you are a Mount employee or student, please access your version of the questionnaire by clicking or selecting this link. You will need to login to myMount to continue on to the form after selecting the link.
All visitors must complete this questionnaire before going to any location on campus. Questionnaires are stored securely and treated confidentially in accordance with all applicable laws. Failure to complete the questionnaire may result in the denial of access to campus. Questions may be directed to University's Director of the Office of Human Resources, Lisa Kobman, at 513-244-4979 or firstname.lastname@example.org.
COMPLETE THE FOLLOWING INFORMATION ABOUT YOUR VISIT TO CAMPUS TODAY. ALL QUESTIONS ARE REQUIRED.
Purpose for today’s campus visit
On campus destination
Name of person(s) you are seeing (enter N/A if not applicable)
Are you a visitor or contractor?
If you are a contractor, enter company name
Answer each of the following questions.
Have you been diagnosed with COVID-19 within the past 14 days?
Do you currently have, or have you recently had, symptoms of COVID-19, such as fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell?
Have you had a recent potential exposure to COVID-19, such as: (a) a household member or intimate partner with COVID-19; (b) providing in-home care for a person with COVID-19 without using recommended infection control precautions; (c) direct contact with a person with COVID-19; or (d) close contact (less than six feet) with a person with COVID-19 for longer than a few minutes?
REVIEW THE FOLLOWING INFORMATION
If you responded YES to any of the above questions, access to campus is not authorized unless you meet the following conditions for authorized access:
If you responded NO to all of the above questions (or if you responded YES to any question and you meet the conditions for authorized access set forth above, as applicable), please read and submit the certification below.
READ AND SUBMIT THE CERTIFICATION.By submitting this questionnaire below, you certify that your responses to the above questions are true, you meet the all of the conditions for authorized access to campus set forth above (as applicable), and that you will comply with the precautions for preventing the spread of COVID-19 as required by the University, including the following: