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Otterbein University is concerned for your safety and the safety of our campus community. We are continuing to monitor the presence of and changes in COVID-19 and we remain in contact with public health officials. Our campus community safety is a shared responsibility. In the interest of ensuring a safe and healthy campus environment, Otterbein requires all visitors to follow the Otterbein Self-Screening Assessment as described below prior to arriving to the Otterbein campus. Your entry onto campus is your certification that you completed Otterbein’s Self-Screening Assessment. We thank you for your cooperation with our shared responsibility of keeping you and our campus community safe and healthy.

 

Visitor Self-Screening Assessment

1. Please take your temperature and if you have a temperature of 100.0 or greater, do not come to campus.
2. Do I have a cough or shortness of breath? If yes, do not come to campus.
3. Do I have at least two of the following symptoms:


• Fever
• Chills
• Repeated shaking with chills
• Muscle pain Headache
• Sore throat
• New loss of taste or smell


If you have at least two of the above symptoms, do not come to campus.
Please consult your medical provider for any other symptoms that are severe or concerning to you. If you have trouble breathing or have persistent pain or pressure in the chest contact your health care provider immediately. We will provide notice if public health officials require an update to our Self-Assessment.

 

 

I Agree
 

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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