COVID-19 Screening Attestation

The safety of the employees, students, families, clients, partners and visitors at Mattituck-Cutchogue School District 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 if you can enter our facilities.

Screening Questions

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  1. Since your last day of work, or last visit here, have you had any of these symptoms?
    • Fever (temperature of greater than 100.0° F in the last 14 days)
    • Cough
    • Shortness of breath or difficulty breathing
    • Chills
    • Repeated shaking with chills
    • Muscle pain
    • Headache
    • Sore throat
    • New loss of taste or smell
    • Congestion or runny nose
    • Nausea or Vomiting
    • Diarrhea
    • Gastrointestinal Tract Symptoms (primarily affecting children only)
    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. In the past 10 days, have you tested positive for COVID-19 OR are you waiting for a COVID-19 test result?

  3. Have you been designated a contact of a person who 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.  I have taken my temperature at home prior to completing this form.
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.


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