Daily Health Screening Form (Royhart)

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This screening form must be completed by all staff and visitors once per day before or immediately after entering any Orleans/Niagara BOCES building. Please note that you are required to disclose any changes to your answers below immediately to your supervisor and the Labor Relations office.

First Name *

Last Name *

Supervisor

Please check all that apply: *

1. I have tested positive through a diagnostic test for COVID-19 within the past 10 days.

2. I have had fever (with a temperature equal to or exceeding 100.0°F), chills, cough, shortness of breath or trouble breathing, new loss of taste or smell, fatigue/tiredness, sore throat, nausea, vomiting, diarrhea, muscle pain, body aches, headaches, nasal congestion, or runny nose within the past 10 days. *

3. I have been in close contact in the past 10 days with someone whom I know has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19. *

4. I have traveled outside the United States during the past 10 days.

5. None of the above

Required

* A listing of COVID-19 symptoms can be accessed at the following link to the Centers for Disease Control and Prevention web site. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. For purposes of the third question above, having been in close contact means having been within six feet of the person for at least 15 minutes cumulatively within 24 hours, starting from 48 hours before the person had symptoms.

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