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.

There is an inherent risk in being in the school during a pandemic.  While the District has taken measures to decrease the likelihood of infection, there is a possibility of infection while present in our buildings.  To reduce the chance of infection, all employees, students and visitors need to work together to decrease the risks to everyone.  To that end, we have developed this questionnaire that must be filled out each morning before arriving at school.   Based on your response, you will be informed if you should report to school or if you can enter our facilities.  If you are responding on behalf of your child, you should answer the questions based on his or her condition.

Screening Questions

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  1. Since your last day of school or work, or last visit here, have you had any of these symptoms?

    • Cough
    • Fever (temperature of greater than 100.0° F in the last 14 days)
    • Shortness of breath or difficulty breathing
    • Fever
    • Chills
    • Repeated shaking with chills
    • Muscle pain
    • Headache
    • Sore throat
    • New loss of taste or smell
    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.

    Unless the school knows you have a health precondition, if you answer YES to any of the symptoms your child should not come to school and will be REQUIRED to get a documented clearance note from a physician or a nurse practitioner to return. 

    If you have a chronic condition that results in one of the symptom(s), you don't need to check "yes" for that symptom(s).

  2. Have you had a positive COVID-19 test within the last 14 days?
  3. Have you had close contact with a confirmed case of COVID-19 case within 14 days?  Close contact means that you were within 6 feet of that person for more than 10 minutes.  
  4. Have you traveled outside the United States, Puerto Rico, Guam or to any of the following states within the last 14 days?

    • Alabama
    • Alaska
    • Arkansas
    • Arizona
    • California
    • Colorado
    • Delaware
    • Florida
    • Georgia
    • Indiana
    • Illinois
    • Iowa
    • Idaho
    • Kansas
    • Kentucky
    • Louisiana
    • Maryland
    • Michigan
    • Minnesota 
    • Missouri
    • Mississippi
    • Montana
    • Nebraska
    • New Mexico
    • Nevada
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Virginia
    • West Virginia
    • Wisconsin
    • Wyoming

 I understand the risks of the COVID-19 disease and recognize the importance of honesty when answering these questions.    

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.