WCT Covid 19 Screen Questionnaire
Please complete this screening form on the day you will be coming to Woodlands. You must be able to answer "No" to all questions in order to come. Thank you for helping to keep our community safe, strong, and healthy.
First Name *
Last Name *
Email Address *
Phone Number *
Names of other family members who will be at Woodlands at the same time.
Please indicate *
Have you tested positive for COVID-19 in the past 14 days? *
Have you had a fever of 100 degrees or higher in the past 14 days? *
Have you experienced any other COVID-19 symptoms in the last 14 days (beyond your baseline)? *
The CDC lists these symptoms for COVID-19:
- Cough
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Diarrhea
Have you or anyone in your household been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19? (Persons in clinical research, clinical care, or clinical training may answer no if they were wearing PPE.) Please do not attend any events at Woodlands if your or any member of your household has been asked to quarantine by a Department of Health in the past 14 days. *
- Close Contact: The New York State Department of Health considers a close contact to be someone who was within 6 feet of an infected person for at least 10 minutes starting from 48 hours before illness onset until the time the person was isolated.
- Proximate Contact: Being in the same enclosed environment such as a classroom, office, or gatherings but greater than 6 feet from a person displaying symptoms of COVID-19 or someone who has tested positive for COVID-19. (NY Department of Health, 3/18/20)
Are you or any member of your household currently required to quarantine? For more information visit: coronavirus.health.ny.gov/covid-19-travel-advisory *
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