Effective August 6, 2021

All visitors must complete this form each day before they enter the building.

If you are a Gladstone badge holder, you do not need to fill out this form but you agree that you have no symptoms of COVID-19 and that you will follow the Gladstone COVID-19 Prevention Protocol when you enter the building.

Do you have any symptoms of COVID-19 now or have you had symptoms within the past 24 hours?

Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. Symptoms of COVID-19 infection as defined by the CDC include:

  • Fever or chills
  • New onset cough
  • Shortness of breath or difficulty breathing
  • Headache
  • Nausea or vomiting
  • Sore or scratchy throat
  • Nasal congestion or runny nose (different from pre-existing allergies)
  • Loss of sense of smell or taste
  • Diarrhea
  • Conjunctivitis (pink eye)
  • Unexplained muscle or body aches

Leave the facility, quarantine at home, speak to your primary care provider about getting a COVID-19 test, and reach out to John Peck in People Services at john.peck@gladstone.ucsf.edu

Are you fully vaccinated (at least 2 weeks since your final dose of the COVID-19 vaccine)?

Welcome to Gladstone. You’re required to wear a KF94 mask at all times in the building. A KF94 mask is the minimum level of respiratory protection allowed and one will be provided if you do not have one.

Click Submit to complete your attestation.

I also attest that the following seven (7) statements are true.

  • I have not been diagnosed with COVID-19 within the previous 10 days, if symptomatic, or 14, if asymptomatic
  • I have not been in contact with someone who has been diagnosed with COVID-19 within the previous 14 days.
  • In the past 14 days, I have not been identified as a contact requiring self-monitoring for symptoms by Gladstone, UCSF, or any public health agency as part of “contact tracing” related to someone diagnosed with COVID-19.
  • I have been in the state of California for at least the past 10 days or have received a negative COVID-19 test result within the past 3-5 days, especially if I visited or traveled through a US county with a “high” or “substantial” level of community transmission, as defined by the CDC.
  • I am entering the facility on essential business and will stay only as long as necessary.
  • I am adhering to the Gladstone COVID-19 Prevention Protocol, as posted around the building and on Hello.
  • I will wear a mask throughout my entire visit.

After you click "Submit", you will see an onscreen confirmation message. You will also receive a confirmation email within 1 minute. Present your confirmation message to the Front Desk Security Guard.

If you do not see a confirmation email, the self-attestation form has NOT been submitted. If you experience any issues, you can contact our webmaster Thomas Becher.

If you do have any symptoms, leave the facility, quarantine at home, speak to your primary care provider, and reach out to John Peck in Human Resources at john.peck@gladstone.ucsf.edu.

If you have questions about this protocol, you can contact either:

Gladstone Institutes has taken extensive precautions to limit the spread of COVID-19 in our facility. To ensure compliance with the latest local public health orders, we are providing you with a summary of actions we have taken.

As of July 20, 2021, Gladstone is operating under modified Level Yellow Operating Status. It’s required that everyone follow, at a minimum, these guidelines.

Please leave the facility. Gladstone is a vaccinated-only facility.