Student/Instructor/Trainee/Resident COVID-19 Attestation

I am a(n) *
Student   Instructor   Trainee   Resident   Other  

If other, please explain.

Enter today's date. *

Semester/Quarter for this rotation *
Winter   Spring   Summer   Fall  

Year *
2022   2023   2024  

First and Last Name *

Email Address *

School Currently Attending/Instructing *

Program *

I attest that I will stay at home if sick. *
Yes   

I will notify my instructor if i am sick. *
Yes   

I attest I will maintain social distancing while eating in breakrooms or lunch areas. I will wear a mask in these areas when not eating or drinking. *
Yes   

I attest I will follow current mask protocols. *
Yes   

I attest I will follow Employee Health Services (406) 751-4189 directives when allowed back to clinicals after an exposure. *
Yes   

By typing my full name in the box below, I attest to all the above. *