COVID-19 Self Check-in Screening

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My role *

Employee

Student

Visitor

Please enter your full name *

Date: *

YYYY

Please review the following questions:

A. Have you had any COVID-19 symptoms in the last 10 days?

Common Symptoms: Fever, chills, cough, shortness of breath, headache, muscle or body aches, loss of taste and/or smell, congestion, nausea/vomiting/diarrhea, runny nose and/or sore throat.

B. Have you had a positive COVID-19 test within the last 10 days?

C. If you are not fully vaccinated, have you had close contact with a confirmed or suspected COVID-19 case within the last 10 days?

D. In the last 10 days, have you traveled out of NY state? Specifics can be found at this website: https://coronavirus.health.ny.gov/covid-19-travel-advisory

E. You are required to verify your temperature daily. Is your temperature over 100 degrees?

Answer: *

NO to A, B, C, D & E.

YES to A, B, C, D or E. "IMPORTANT: If your answer is YES to any of the questions, DO NOT ENTER the building. Employees, please contact your Supervisor immediately."

I have answered these questions truthfully to protect my own health and the health of those around me. I agree to follow NYS guidelines. *

I Agree

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