Health Screening Attestation
Please complete this form daily prior to your arrival. This information will be maintained separately from other visitor sign-in information for confidentiality.
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Last Name *
First Name (if filling out for your child, please put their name) *
Phone Number *
Phone contact information is requested for tracing and tracking purposes in the event of a positive case of COVID-19 in this building.
Have you had any symptoms of COVID-19 in the past 14 days, including a temperature above 100° F? *
*According to the CDC guidance on “Symptoms of Coronavirus,” people with COVID-19 have had a wide range of symptoms reported, ranging from mild symptoms to severe illness. Symptoms of COVID-19 include, but are not limited to: cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, or new loss of taste or smell.
Required
Have you tested positive for COVID-19 in the past 14 days? *
Have you been in close contact with a person who has or is suspected of having COVID-19 in the past 14 days? *
Required
Have you traveled internationally or from a state with widespread community transmission of COVID-19 per the NYS Travel Advisory in the past 14 days? *
Further information on the list of states subject to the travel advisory can be found at: https://coronavirus.health.ny.gov/covid-19-travel-advisory.
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