As directed by the New York State Department of Health (NYSDOH) as well as the Dutchess County Department of Health (DCDOH), before you are allowed to enter into one of our schools and or office buildings/facilities, you are required to take your temperature and answer ALL questions listed below. This practice must occur daily and you may ONLY submit your reply the actual day of after 12:00 AM. If your submission is completed prior to 12:00 AM, it will not be valid and you will have to re-submit the form prior to entering into our facilities.
IMPORTANT: By checking yes that you have a fever of 100.0 F or greater and/or that you have responded affirmatively (Yes) to one or more of the following questions related to COVID 19, you CANNOT report to work/school. A follow up email/phone conversation will occur with appropriate next steps.
School/Work address only email address
Indicate your school or office building you primarily work/attend:
Van Wyck JHS
John Jay HS
Orchard View AHS
Roy C. Ketcham HS
Central Office Hopewell
Facilities at RCK
Bus Garage at FP
Bus Garage at VWJHS
Bus Garage at WJHS
Out of District Placement i.e., DC BOCES, Green Chimneys, etc
Please identify either student or staff.
Do you have a temperature of greater than 100.0°F?
Please complete the sentence: In the last two weeks (fourteen days)...
NO, I have NOT made contact with anyone diagnosed with COVID-19.
YES, I have MADE contact with someone diagnosed with COVID-19.
Have you had any of the following symptoms in the past 24 hours: Fever or chills, 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?
If you answered yes to having any of the symptoms above in Question #6, which symptoms have you had in the past 24 hours? Please ensure that you select "None" if you have not displayed any of these symptoms in the past 24 hours.
Fever or chills
Shortness of breath or difficulty breathing
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
None of the above
Have you traveled to and stayed more than 24 hours in a state that has a significant degree of community-wide spread of COVID-19 ("restricted" as determined by NYS)?
No, I have not traveled outside of New York State in the past 24 hours.
Yes, I have traveled outside of New York State to a state(s) that are not listed as "restricted" per NYS Health Dept.
Yes, I have traveled outside of New York State, in the past 14 days, to a state that is listed as a "restricted state" per NYS.
Please indicate the location City(s), Town, State as well as date and time you traveled.
By checking this box I am confirming the above information is accurate.
I confirm the information provided is accurate.
Send me a copy of my responses.
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This form was created inside of Wappingers Central School District.