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    Coastal Bend College
     Testing Center Screening/Waiver Form

     We will start In-Person testing again with the new TSIA2 on January 11, 2021.  
     
     

    Please initial by each statement to show that you’ve read the information and will abide by it.
     
     

    Statements:  

    Initials Required in this Column.  

    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.  

       

    We are not able to provide testing services to those without a face mask, nor are we able to supply face masks to candidates.  

       

    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.
     
     

       

    Candidates must bring their own face masks which will be required to be worn throughout the entire test appointment.  

       

    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. 
     
     

       

    Coastal Bend College’s Testing Centers will require and enforce social distancing of at least 6-feet.  

       

    No guests are allowed in the center.  

       

    COVID-19 Active Screening Questionnaire  

    Full Name – first and last name:    

       

    Today’s Date:  

       

    Coastal Bend College Student ID Number:    

       

    Coastal Bend College E-mail Address:    

       

    Phone Number:    

       

    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. 

                Within the last 2 -14-days, have you experienced a new cough that you cannot attribute to another health condition?   

     

      

                   

      

               Within the last 2 - 14-days have you experienced new shortness of breath that you cannot attribute to another health condition?  

      

                   

      

                Within the last 2 - 14-days, have you experienced a new sore throat that you cannot attribute to another health condition?  

      

                   

      

                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?  

      

                   

      

                Within the last 2 - 14-days, have you had a temperature at or above 100.4 or the sense of having a fever?  

      

                   

     

                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)  

      

                   

      

                 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)?    

      

                   

      

                Have you traveled outside the United States or to any high-risk location within the last 2 - 14 days?  

      

                   

      

             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?  

      

                   

      

    Have you experienced loss of taste or smell within the last 2 - 14 days?    
     

     

     

    (Coastal Bend College does not discriminate on the basis of race, creed, color, national origin, gender, age, or disability.) 
    Created 6/23/20
    Revised 1/12/21
    www.coastalbend.edu/TCSW/