Self-Certification Form

This certification must be completed within 2 hours prior of starting your work shift and before you arrive on campus.

* = Required Field

I certify that I...

  • Have no signs of a fever or a measured temperature above 100.3 degrees or greater, a cough or trouble breathing within the past 24 hours
  • Have not had Close Contact with an individual diagnosed with COVID-19. Close Contact means living in the same household as a person who has tested positive for COVID-19, caring for a person who has tested positive for COVID-19, being within 6 feet of a person who has tested positive for COVID-19 for about 15 minutes, or coming in direct contact with secretions (e.g., sharing utensils, being coughed on) from a person who has tested positive for COVID-19, while that person was symptomatic
  • Have not been asked to self-isolate or quarantine by their doctor or a local public health official