Security Aides Staff - Uniondale Union Free School District Health Screening Questionnaire Related to COVID-19
*Please complete this form BEFORE entering your assigned school building EACH day NO later than 3pm of the day before you are to report to work, for the Novel Coronavirus (COVID-19)*

1. You MUST be logged into your Uniondale Email to complete form
2. Complete and submit this form.
3. Your submission will be shared with your Building Administration & Nurse Administrator
4. Coronavirus Hotline Number: 1-888-364-3065
Email address *
Staff Member's Full Name: *
Staff Member's Title: *
Building(s) Assignment or School Building *
Required
COVID-19 - Are you exhibiting any symptoms as listed below?: *
To the BEST of your knowledge:
Yes
No
Fever of 100.4 degrees Farenheit or higher?
Cough, Sore Throat, Shortness of Breath, Chills?
Muscle Pain, headache and/or new loss of taste or smell?
COVID-19 Contact or Diagnosis *
To the BEST of your knowledge:
Yes
No
Have you had any person-to-person contact with someone who has exhibited COVID-19 symptoms within the last 14 days?
Have you visited an area where there has been a significant outbreak of COVID-19 activity in the last 14 days?
Have you been diagnosed with COVID-19?
Based upon Governor Cuomo’s Executive Order 205, issued June 25, 2020, the following States meet the criteria for required quarantine - name the Restricted State(s) you have visited listed in the link below within the last 14 days: https://coronavirus.health.ny.gov/covid-19-travel-advisory. IF you have NOT traveled to any of the named States, then respond with N/A *
Specify which State(s) below OR respond with N/A (Not Applicable)
Exact Return Date from Restricted State(s) *only if applicable:
MM
/
DD
/
YYYY
COVID-19 Please confirm by checking the appropriate box: *
To the BEST of your knowledge:
Yes
No
N/A
Have you had a fever within the past 72 hours (3 full days) or used any fever-reducing agents?
Have you experienced an improvement of symptoms
Has it been 14 days or more since symptoms first appeared
Have you been diagnosed with COVID-19?
Date of Positive COVID-19 Diagnosis:
IF you answered "Yes" to the above question, then indicate the date diagnosed below:
MM
/
DD
/
YYYY
Best Contact Phone Number including area code *
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