Poland - Sign in Screening

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This form is the Poland CSD Screening Sign-In, and must be signed when entering ANY of our buildings. This is a requirement.

Email *

Please type your name if you are NOT employed by our District.

What area are you entering? *

Main Building

Bus Garage

Other:

If you answer YES to any of the following questions, do not enter the building. Contact your department administrator, and return home unless you have an official release from isolation or quarantine notice that was issued in the last 14 days. - Have you experienced any COVID-19 symptoms in the past 14 days that can not be otherwise explained? - Have you had a positive COVID-19 test in the past 14 days? - Have you been in close contact with anyone with a confirmed or suspected case of COVID-19 in the past 14 days? - Have you traveled to or from your residence and not followed the NYS Travel Advisory protocols as prescribed? - I've taken or had my temperature taken before entering the building today and it is ABOVE 100.0? *

Yes

By entering your first and last name in the field below, you are certifying that all the above answers are true to the best of your knowledge. Please enter your first and last name: *

Send me a copy of my responses.

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