Employee COVID-19 Self-Certification and Verification Form

In response to the COVID-19 pandemic and in order to ensure a safe and healthy environment for our campus community, guidance from the Illinois Community College Board and the Illinois Board of Higher Education provides that employee health screenings may be on an automated or self-monitoring basis. All employees will conduct a daily health screening on each day prior to their arrival for work at any college building or facility and report consistent with the parameters outlined below, until otherwise notified by the college in writing.

This form must be submitted by September 10, 2021.

Certification and Verification of Daily Health Screening

I will conduct a daily health screening of myself to determine if I have any new or unusual COVID-19 symptoms:

  • Temperature of 100.4 (or greater) degrees Fahrenheit/38 degrees Celsius;
  • Cough;
  • Shortness of breath or difficulty breathing;
  • Chills;
  • Fatigue;
  • Muscle and body aches;
  • Headache;
  • Sore throat;
  • New loss of taste or smell;
  • Congestion or runny nose;
  • Nausea and/or vomiting;
  • Diarrhea; or
  • Any other COVID-19 symptoms identified by the Centers for Disease Control (CDC) or Illinois Department of Public Health (IDPH).

By reporting to work on any given day, I am certifying and verifying that I am not experiencing any COVID-19 symptoms. If I experience any of the above symptoms at any time during my work day, I will immediately notify immediate supervisor and Leslie Hofer, Director of Human Resources, isolate myself away from other employees and students pending further direction from the college/university, and provide necessary information as requested.

If my daily health screening reveals that I am experiencing any COVID-19 symptoms, I will notify the college in writing of my absence from campus and the symptoms I am experiencing by sending an email to immediate supervisor and Leslie_Hofer@ivcc.edu, and provide necessary information as requested. I will also provide notice of my absence from campus and necessary information if within 14 days before any work day, a member of my household has had “close contact” (definition below) with someone who tested positive for COVID-19, and my household member is also experiencing symptoms of COVID-19 or has tested positive for COVID-19.  I will await further direction from the college before coming onto campus.

For COVID-19, the CDC defines “close contact” as, any individual who was within 6 feet of an infected person for at least 15 minutes (consecutive or non-consecutive within a 24 hour period) starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to positive specimen collection) until the time the patient is isolated. Briefer periods of exposure may qualify an individual as a close contact if there is direct physical contact (kissing or hugging), eating or drinking utensils were shared, or the infected person sneezed, coughed or transferred respiratory droplets to the individual. Per the CDC, an individual that tested positive for COVID-19 within the past three (3) months may be excluded from the 14-day quarantine protocol for a “close contact.”

Certification and Verification of Other COVID-19 Related Exposures

I will notify the college that I will be absent from campus pending further direction from the college if: (1) I receive a diagnosis of COVID-19; (2) I am suspected of having COVID-19; (3) I come in close contact (definition above) with an individual who tested positive for COVID-19 or is suspected of having COVID-19; or (4) I have traveled internationally. If IVCC Human Resources staff or a designee contacts me to gather additional information related to the reason(s) for my absence, I will provide necessary information as requested.

By reporting to campus on any given day, I am certifying and verifying that I am not presently subject to an isolation or quarantine protocol related to COVID-19.