COVID-19 Screening Attestation

The safety of our employees, students, families, 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. 

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 every day prior to entering a facility. Based on your response, you will be informed if you should report to work or if you can enter our facilities.

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 role.

    Has the employee/visitor/student, or anyone in the household currently have (or have had in the last 10 days) one or more of these new or worsening symptoms? (If yes, ALL household members must remain at home)

    • A temperature greater than or equal to 100.0° F (37.8° C)
    • Feel feverish or have chills
    • Cough
    • Loss of taste or smell
    • Fatigue/feeling of tiredness
    • Sore throat
    • Shortness of breath or trouble breathing
    • Nausea, vomiting, diarrhea
    • Muscle pain or body aches
    • Headaches
    • Nasal congestion/runny nose

    Note: Answer “yes” if the symptoms the employee/visitor/student or anyone in the household have experienced in the last 10 days are of greater intensity or frequency than what you normally experience.

    In the past 10 days, has the employee/visitor/student, or ​household member ​test positive for COVID-19, OR is the employee/visitor/student  ​or a household member ​waiting for a COVID-19 test result due to symptoms or exposure?

    Has the employee/visitor/student been designated a direct contact of a person who tested positive for COVID-19 by the health department (DOH), the district, or by the person (Index) who tested positive?

    In the past 10 days, has the employee/visitor/student traveled internationally to a CDC level 2 or 3 COVID-19 related travel health notice country; OR has the employee/visitor/student traveled to any state other than Vermont, Massachusetts, Connecticut, Pennsylvania, or New Jersey? 

    1. No.
    2. Yes, employee/visitor/student was out of state for less than 24 hours, and employee/visitor/student took or will take a COVID-19 test on the 4th day after my arrival in NY.
    3. Yes, employee/visitor/student was out of state for more than 24 hours, and employee/visitor/student took a COVID-19 test within 72 hours PRIOR to my arrival in NY, and took a second COVID-19 test on the 4th day AFTER my arrival in NY, and got negative results on both tests.
    4. Yes, employee/visitor/student was in a noncontiguous state and did not take a COVID-19 test as per the NYS guidelines (Note: will need to quarantine for 10-day from the day you returned to NY)

     


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.
Visitors 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.


Employee/Student/Visitor:  If filling out this form, please provide your 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.