Employee COVID-19 Self Check-In Questionnaire
IMPORTANT: Employees, Students and Visitors must complete this form prior to gaining access to our offices and school buildings as per NYS guidelines.
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Enter your name *
Will you be coming to work today? *
If No, reason for your absence
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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, headache, loss of taste and/or smell, congestion, runny nose and/or sore throat.

B. Have you had a positive COVID-19 test within the last 10 days?

C. Have you had close contact with a confirmed or suspected case of COVID-19 case within the last 14 days?

D. Has your temperature been verified to be over 100 degrees?

E. Have you traveled internationally or from a state with widespread community transmission of COVID-19 per the NYS Travel Advisory in the past 14 days?
Have you answered yes to any of the above questions? *
Have you had your temperature taken today? *
I have answered these questions truthfully to protect my own health and the health of those around me. I agree to follow NYS and Roxbury Central School guidelines. *
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