COVID-19 Self Check-in Screening
Sign in to Google to save your progress. Learn more
My role *
Please enter your full name *
Date: *
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?

Answer: *
I have answered these questions truthfully to protect my own health and the health of those around me. I agree to follow NYS guidelines. *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Cherry Valley Springfield CS. Report Abuse