JCSB Building and JCS OM COVID-19 pre-screening form

Name Name First Last
I am a:

I am a: Employee Visitor
Name of person you are visiting:
Location of Work:

Location of Work: Park Heights Owings Mills Community Location
Location Visiting:

Location Visiting: Park Heights Owings Mills
Date you will be in the building Date you will be in the building / MM / DD YYYY
Email

Please enter email if you wish to receive the daily code in your email. If you do not enter email, you must write down the code you receive upon submission.
Phone Phone - ### - ### ####
Have you been confirmed or suspected to have COVID-19 as determined by a health care provider in the past 10 days?

Have you been confirmed or suspected to have COVID-19 as determined by a health care provider in the past 10 days? Yes No
Have you been in close contact (within 6 feet) with an individual who is under investigation for COVID-19 or who has been diagnosed to have COVID-19 as determined by a health care provider in the past 10 days? * * If you have notified HR previously and been cleared to return to work, please select no.

Have you been in close contact (within 6 feet) with an individual who is under investigation for COVID-19 or who has been diagnosed to have COVID-19 as determined by a health care provider in the past 10 days? * * If you have notified HR previously and been cleared to return to work, please select no. Yes No
Are you exhibiting any signs of illness?

Are you exhibiting any signs of illness? Yes No
***I will notify JCS if I or anyone in my household tests positive for COVID-19 within 14 days of my visit to the building.

JCSB Building and JCS OM COVID-19 pre-screening form

JCSB Building and JCS OM COVID-19 pre-screening form

***I will notify JCS if I or anyone in my household tests positive for COVID-19 within 14 days of my visit to the building.