COVID-19 Self Check-in Screening
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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:
E. You are required to verify your temperature daily. Is your temperature over 100 degrees?
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.
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This form was created inside of Cherry Valley Springfield CS.