ICD Daily Staff Health Questionnaire
Please complete this form prior to your arrival to ICD. This information is required as part of our adherence to the New York State Department of Health (NYSDOH) guidelines. We will take your temperature upon arrival. If you have a fever of 100 degrees or higher OR show any of the COVID-19 symptoms below, we will request that you do not continue at work, as is recommended by NYSDOH.

Email address *
What is your FULL NAME? *
Have you experienced any of the following COVID-19 symptoms in past 14 days: fever, chills, cough, shortness of breath/difficulty breathing, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, new loss of smell or taste? *
Have you had a positive diagnostic COVID-19 test in past 14 days? *
Have you had close contact (within 6 feet for 10 or more minutes) with a confirmed or suspected COVID-19 case(s) in past 14 days? *
Have you traveled to a high infection area for COVID-19 anywhere in the US (i.e., state with widespread community transmission per the New York State Travel Advisory) or internationally within the last 14 days that would typically require quarantine and have not met criteria for release (i.e., quarantined at least 3 days and tested negative on the 4th day for early release)? *
I endorse that all of my responses are true at the time of completing this form. I understand that if I answered YES to experiencing ANY COVID-19 symptoms, OR if I answered YES to having a positive COVID-19 test in the past 14 days, OR if I answered YES to having close contact with a confirmed or suspected case of COVID-19, that I will not be able to enter the ICD building for work and that I need to call 777-2829 to call out. Additional questions can be directed to Tom Popielarski at RF. By typing my full legal name below, I confirm my health status to the best of my knowledge by electronic signature. *
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