COVID-19 Screening Attestation

The safety of the employees, students, families, clients, partners and visitors remains our top priority. As the COVID-19 outbreak continues, we will closely monitor the situation and will periodically update our guidance based on current recommendations from New York State.

Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions (e.g. serious heart disease, chronic lung disease or asthma, immunocompromised, severe liver disease, etc.) might be at higher risk for severe illness from COVID-19. If you are concerned about underlying medical conditions, please consult with your personal medical health care provider.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce, we are conducting a simple screening. Your participation is important to help us take precautionary measures to protect you and everyone in this facility. We request you complete this screening everyday prior to entering a facility.

Based on your response, you will be informed if you should report to work or to contact your Supervisor/Building Administrator.

Screening Questions

Please select a valid location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid sub-location.
Please select a valid role.

  1. Since your last day of work, or last visit here, have you had any of these symptoms?
    • Cough
    • Shortness of breath or difficulty breathing
    • Fever (100.0)
    • Chills
    • Repeated shaking with chills
    • Fatigue
    • Muscle pain
    • Headache
    • Sore throat
    • New loss of taste or smell
    • Congestion or runny nose
    • Nausea or vomiting
    • Diarrhea
    Note: Answer “yes” if the symptoms you have experienced in the last 14 days are of greater intensity or frequency than what you normally experience.
  2. Have you or anyone in your household tested positive for COVID-19 in the past 10 days or are you currently waiting for a COVID-19 test result? 
  3. In the past 24 hours, have you (Faculty/Staff Member) or your child (BMCHSD Student) been designated a contact of a person (6 feet or closer for at least 15 minutes) who has tested positive for COVID-19 by a local health department?
  4. In the past 14 days, have you/your child traveled internationally to a CDC level 2 or 3 COVID-19 related travel health notice country; OR, in the past 3 days, have you returned from spending more than 24 hours in any state other than Vermont, Massachusetts, Connecticut, Pennsylvania or New Jersey?

Employees: I am doing my part to keep myself and others safe and I am following the practices outlined in our COVID-19 safety protocols.
Guests and students: I am doing my part to keep myself and others safe and am following the practices outlined in New York State's safety protocols.


Parent/Guardian: If filling out this form on behalf of a student, please provide the student's first and last name.
Valid first name is required.
Valid last name is required.
Please enter a valid email address for location access.
Please enter a valid phone number for location access.