Visitor Screening Survey - Clinton CSD
This form is for visitors who have planned meetings taking place inside one of the school buildings during the day. If you have answered yes to any of these questions, you will not be allowed entry.
Enter Your First and Last Name *
Enter Your Phone Number (xxx-xxx-xxxx) *
Upon taking your temperature today, was it greater than 100.0 degrees Fahrenheit? (37.7 Celsius) *
In the last 14 days, have you had any of these symptoms? Fever (temperature of greater than 100.0°F in the last 14 days), CoughShortness of breath or difficulty breathing, ChillsRepeated shaking with chills, Muscle pain, Headache, Sore throat, Gastrointestinal Tract Symptoms (primarily affecting children only)New loss of taste or smell, Answer “yes” if the symptoms you have experienced in the last 14 days are of greater intensity or frequency than what you normally experience. *
Have you had a positive COVID-19 test within the last 14 days? *
Have you had close contact with a confirmed or suspected case of COVID-19 within 14 days? *
Have you traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days? *
Never submit passwords through Google Forms.
This form was created inside of Clinton Central School. Report Abuse