COVID-19 Health Screening
You must complete this questionnaire before leaving your house to come to New York Live Arts or any organizational events. If you answer YES to any of the questions, or do not score a 7, you are NOT CLEARED and should not come to work.

Please contact the Site Safety Manager, Alden Henderson, ahenderson@newyorklivearts.org for further discussion.

● Anyone who develops symptoms of COVID-19, is infected with COVID-19, or reports
close contact with infected individuals should not go to work, contact their direct supervisor, follow safety protocols, and should seek medical evaluation and care.
● Anyone reporting to work while displaying symptoms will be directed to leave the venue, isolate themselves, be referred to appropriate medical services, and follow reporting protocols.

All responses will be kept confidential.
Email address *
Name *
Contact Information (phone number)? *
Do you currently have a fever of 100.4 degrees F or greater? *
1 point
Do you have a cough or shortness of breath that began within the past 14 days? *
1 point
Do you have or have you experienced the following symptoms within the past 14 days: chills / shaking, unexplained muscle pain, headache, sore throat, new loss of taste or smell? *
1 point
In the past 14 days, have you been in close contact with anyone who has exhibited any of the above symptoms or tested positive for COVID-19? *
1 point
In the past 14 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab? (not a blood test) *
1 point
What was the date of your last COVID-19 test?
MM
/
DD
/
YYYY
In the past 14 days, were you notified by your medical provider or the NYC Test and Trace team to remain home because of COVID-19? *
1 point
In the past 14 days, have you traveled from or knowingly been in extended contact with someone who has been in a high risk state or country? *Please refer to https://coronavirus.health.ny.gov/covid-19-travel-advisory for the complete list of states affected. *
1 point
Which space will you be using today? *
Required
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