Sign-In and Self-Assessment Form

Sign-In and Self Assessment

Within the last ten (10) days, have you been diagnosed with COVID-19 or had a test confirming you have COVID-19? *

Have you been within six feet (6’) of a person with a lab-confirmed case of COVID-19 for at least five (5) minutes, or had direct contact with their mucus or saliva, in the past fourteen (14) days?

In the last forty-eight (48) hours, have you had any of the following NEW symptoms?

Fever of 100.5° F (38° C) or above, or possible fever symptoms like alternating chills and sweating? *

Cough? *

Trouble breathing, shortness of breath, or severe wheezing? *

Chills, or repeated shaking with chills? *

Muscle aches? *

Sore throat? *

Diarrhea? *

A recent loss of sense of smell or taste, or a change in taste? *

To be admitted into Fort Mason building, you MUST wear a face-covering (mask) that covers your mouth and nose.

Name *

First

Last

Email *

Organization *

Intended Arrival Time *

Please note: all sign-in and self-assessments must be completed no more than six (6) hours prior to your intended arrival time. Additionally, you must complete a sign-in and self-assessment EACH TIME you plan to enter a building on campus.

Intended Departure Time *

I affirm that all my answers are true to the best of my knowledge *

Sign-In and Self-Assessment Form

If the answer to any question is YES, you MAY NOT enter Fort Mason Center for Arts & Culture. Thank you for your understanding as we work to keep our community safe.