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Holland Central Schools: Visitor Check-in Form

All visitors must complete the questions below to gain access to the building.

Visitor Name: *

Date Visiting: *

School(s) Visiting: *

Holland Elementary School

Holland Middle School

Holland High School

Bus Garage

Reason for visit, and who you are visiting: *

Do you currently have (or had in the last 10 days) one or more of these *new or worsening* symptoms? Symptoms include: temperature greater than or equal to 100.0 F, feel feverish or have chills, cough, shortness of breath or trouble breathing, fatigue/feeling of tiredness, muscle pain or body aches, headaches, loss of taste or smell, sore throat, congestion/runny nose, nausea, vomiting, diarrhea. *

Yes - You CANNOT Enter

In the last 10 days, have you tested positive for COVID-19 or are you still waiting for the test result? *

Yes

In the last 10 days, have you been designated a contact of a person who tested positive for COVID-19 by a local health department? *

Yes

In the last 10 days, have you traveled internationally to a CDC level 2 or 3 COVID-19 related travel health notice country; or traveled to a non-contiguous state? (Contiguous states include: Pennsylvania, New Jersey, Connecticut, Massachusetts, and Vermont)? *

Yes

Acceptance *
Visitor Attestation

I confirm that I am not showing symptoms and have replied NO to all questions above.

I confirm that I am showing COVID symptoms, OR have replied YES to one or more questions above.

Reason (optional)

Your Name

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