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.

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 role.

  1. In the last 10 days, have you had a temperature greater than or equal to 100.0° F (37.8° C)?

  2. In the last 10 days, have you had any of these new or worsening symptoms?

    • Feel feverish or have chills
    • Cough
    • Shortness of breath or difficulty breathing
    • Loss of taste or smell
    • Fatigue/feeling of tiredness
    • Muscle pain or body aches
    • Headaches
    • Sore throat
    • Nausea, vomiting, diarrhea
    • Nasal congestion/runny nose
  3. In the past 10 days, have you tested positive for COVID-19 test OR are you waiting for a COVID-19 test result?
  4. Have you been designated a contact of a person who tested positive for COVID-19 by a local health department? 
  5. In the past 14 days, have you 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.
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.