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.

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.
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. Since your last day of school/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
    • 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. Have you had a positive COVID-19 test within the last 14 days?
  3. Have you had close contact (within 6 feet) with a person confirmed of having a case of COVID-19 for at least 10 minutes within the last 14 days?
  4. Have you traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory (https://coronavirus.health.ny.gov/covid-19-travel-advisory) and CDC guidelines (https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html) in the past 14 days?

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 will not report to work if I answered yes to any of the questions.
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.