Request Entry To Region 18 ESC Facilities
Attestation of Health Status Related to COVID-19
In order to access Region 18 ESC facilities, all individuals must provide the following information. A separate form is required for each individual entering the facility.

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.

Are you experiencing any COVID-19 related symptoms?	Yes No
Have you recently been in contact with anyone with a confirmed case of COVID-19?	Yes No
Facility Entry Information:
Entry Date *
Requestor Information:
First Name *
Last Name *
Email Address *
Mobile Phone# *
By submitting this form, I attest that all the information provided is true and accurate to the best of my knowledge.