ATTESTATION of No COVID-19 Symptoms

Visitors must complete this before entering the Buck campus for the 1st time.

Buck COVID-19 Protocol – updated November 1, 2022

Buck Institute has taken extensive precautions to limit the spread of COVID-19 on our campus and ensure compliance with the latest Public Health orders and Cal/OSHA standards.

This form attests that visitors and guests will follow all relevant Buck rules and regulations. Visitors and guests must certify below that they do not have any symptoms suspicious for COVID-19, and should not currently be in isolation if recently diagnosed with COVID-19.

Buck Institute is taking the following measures to ensure the health of all individuals:

  • Individuals are not to enter the building if they are sick, and must follow Buck testing, isolation, and return to work protocols.
  • Recent high-risk exposures may require individuals to mask indoors to protect others.
  • Self-protection with high-quality masks is encouraged.
  • Disinfecting break rooms, restrooms, common areas, and high contact surfaces has increased.

Agreement

  • I understand wearing a mask indoors is optional although recommended for additional protection. I further understand I may request an N95 mask upon entry. The Buck Institute cannot eliminate the risk of acquiring COVID-19 on its campus.
    1. I certify that in the past 10 days I have not had any of the following symptoms of COVID-19 infection (unless fully explained by a pre-existing condition):
      • Fever (≥37.8°C/100°F)
      • New onset cough
      • Shortness of breath or difficulty breathing
      • Headache
      • Nausea
      • Sore throat
      • Nasal congestion or runny nose (different from pre-existing allergies)
      • Loss of sense of smell or taste
      • Diarrhea
      • Conjunctivitis (pink eye)
      • Body aches
    2. I am not currently taking any medication in order to mask symptoms of fever and infection such as acetaminophen, ibuprofen, aspirin, or cough medications.
    3. I have not been diagnosed with COVID-19 within the previous 10 days.
    4. I have not in the previous 10 days been in close unmasked contact with someone sick with COVID-19, and no one in my household is currently sick with COVID-19 or symptoms suspicious for COVID-19.

  • * Denotes a required field