Coastal
Bend College
Testing Center Screening/Waiver
Form
This form no longer needs to be submitted for In Person Testing Go ahead and leave this screen.
Please
initial by each statement to show that you’ve read the information and will
abide by it.
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Statements:
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Initials
Required in this Column.
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Please be aware that Coastal
Bend College’s Testing Center require that a face mask be worn while in the testing center during the COVID-19 pandemic.
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We are not able to provide
testing services to those without a face mask, nor are we able to supply face
masks to candidates.
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Due to the continued COVID-19
Coronavirus pandemic, we will continue to follow CDC protocol to protect and
keep our students, our community, and our center safe.
Please read and pay attention to our directions.
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Candidates must bring their
own face masks which will be required to be worn throughout the entire test appointment.
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In order to keep contact to a
minimum – Testing candidates are asked to leave ALL personal items (including
cell phones) in their personal vehicle with the exception of their Photo
ID.
Such items brought into the
Testing Center will be collected and placed at a designated location.
The Testing Center staff will not be
responsible for lost or stolen items.
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Coastal Bend College’s Testing
Centers will require and enforce social distancing of at least 6-feet.
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No guests are allowed in the center.
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COVID-19
Active Screening Questionnaire
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Full Name – first and last
name:
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Today’s Date:
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Coastal Bend College Student
ID Number:
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Coastal Bend College E-mail
Address:
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Phone Number:
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This form will be updated as
the CDC and THECB information on COVID-19 continues to change. Your health and well-being are of the
upmost importance and we are taking measures to keep the facility/office/lab
a safe environment for employees as well as the individuals under our charge
and the public. Therefore, anyone
coming into the facility/office will be screened and part of our screening
process is asking the following questions.
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Within the last 2 -14-days, have you
experienced a new cough that you cannot attribute to another health
condition?
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Within the last 2 - 14-days have you experienced
new shortness of breath that you cannot attribute to another health
condition?
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Within the last 2 - 14-days, have you
experienced a new sore throat that you cannot attribute to another health
condition?
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Within the last 2 - 14-days, have your experienced
new muscle aches that you cannot attribute to another health condition or a
specific activity such as physical exercise?
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Within the last 2 - 14-days, have you had a
temperature at or above 100.4 or the sense of having a fever?
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Within the last 2 - 14-days, have you had close
contact, without the use of appropriate PPE, with someone who is currently
sick with suspected or confirmed COVID-19?
(Note: Close contact is defined
as within 6 feet for more than 10 consecutive minutes)
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Have you experienced flu-like symptoms in
the last 2 - 14 days (to include fever, chills, cough, sore throat, respiratory illness, congestion or runny nose, fatigue, difficulty breathing)?
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Have you traveled outside the United States or to any high-risk location within the last 2 - 14 days?
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Have you been in close contact with anyone
who has traveled outside the United States or to any high-risk location in the last 2 -14 days?
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Have you experienced loss of taste or smell within the last 2 - 14 days? |
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