CS COVID-19 Screening Form
Please complete this form daily (when working in our schools or buildings) and submit it to your direct supervisor each day you work until further notice.
Last Name *
First Name *
In which Department do you work? *
Have you traveled to any restricted state in the last 14 days? See list of current restricted states here: https://coronavirus.health.ny.gov/covid-19-travel-advisory *
Have you tested positive for COVID-19 within the last 14 days? *
Have you been in close contact with anyone who has tested positive for COVID-19 in the last 14 days? *
Are you currently experiencing unexplained instances (or a worsening) of the following symptoms in the past 14 days? *
Yes
No
Fever at or above 100
Lingering Headache
Loss of Taste or Smell
Shortness of Breath
Muscle Aches
Diarrhea
Sore Throat
Prolonged Runny/Stuffy Nose
Cough
Fatigue
Nausea or vomiting
Note:
The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to your supervisor or Human Resources Director. If you have a fever, then please notify your supervisor and you will not be working in District that day. You should also consult your doctor. If you do not have a fever but you are experiencing any of the other symptoms and those symptoms are not normal to you because of an underlying condition such as migraines, allergies, etc., please don't put others in jeopardy and consult your doctor. If the answer is yes to any of the questions on the screening form, you will not be allowed to enter the building and will be directed to contact a health care professional. Preventing the spread of COVID-19 is essential.
Certification:
By submitting this form, I hereby certify that the responses provided above are true and accurate to the best of my knowledge.
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