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Request Entry To Region 18 ESC Facilities
Attestation of Health Status Related to COVID-19

In order to access Region 18 ESC facilities during the suspension of normal business operations, all individuals must provide the following information. A separate form is required for each individual entering the facility.

Please respond to each item relating to yourself and individuals you have come in contact with and submit below.

All individuals are required to check their temperature while at home and prior to traveling to and entering the facility. Individuals answering "Yes" to one or more of these items will NOT be allowed to access or work in the Region 18 ESC facility.

Facility Entry Information:

Requestor Information:

By submitting this form, I attest that all the information provided is true and accurate to the best of my knowledge.