COVID-19 Screening Attestation

The safety of the employees, students, families, clients 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.     

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce, we are conducting a health screening.  Your participation is important to help us take precautionary measures to protect you and everyone in this facility.  This questionnaire must be completed each day and prior to entering a building or facility.  If you respond “yes” to any of the questions, DO NOT report to your school or enter any Roosevelt school building or facility!  Immediately contact your principal/supervisor for further instructions and your health care provider for a health assessment and testing. 

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 role.
  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
    Note: Answer “yes” if the symptoms you have experienced in the last 10 days are of greater intensity or frequency than what you normally experience.
  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 close contact (6 feet or closer for at least 15 minutes) 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 have you traveled to 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.
Students, guests and vendors: 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.
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