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.

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 if you can enter our facilities.

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

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

  1. Do you currently have (or have had in the last 10 days) one of 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 or diarrhea
    • Muscle pain or body aches
    • Headaches
    • Nasal congestion or runny nose
  2. In the past 10 days, has anyone in your household tested positive for COVID-19?
  3. Have you been designated a contact of a person who tested positive for COVID-19 by a local health department?
  4. Are you waiting for the results of a COVID-19 test that was performed due to the presence of new or worsening symptoms?
  5. In the last 14 days, have you 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 following the practices outlined in our COVID-19 safety protocols.

Visitors: I certify that my responses to this form are accurate. 


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.