COVID-19 Screening Attestation

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This is not a substitute for professional medical advice, diagnosis, or treatment of disease or other conditions, including COVID-19. Always consult a medical professional if you have questions, are experiencing symptoms or if you have an emergency.

Screening Questions

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  1. Do you/your child currently have (or have had in the last 10 days) one or more of these new or worsening symptoms?

    *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

  2. In the past 10 days, have you/your child tested positive for COVID-19 OR are you waiting for a COVID-19 test result?

  3. Have you/your child been designated a contact of a person who tested positive for COVID-19 by a local health department?

  4. In the last 14 days, have you/your child traveled internationally to a CDC level 2 or 3 COVID-19 related travel health notice country or traveled to a state or territory on the NYS Travel Advisory List?


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.