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

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 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 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 work, or last visit here, have you had any of these symptoms?
    • Fever (temperature of greater than 100.0° F in the last 10 days)
    • Runny Nose
    • Cough
    • Shortness of breath or difficulty breathing
    • Chills
    • Repeated shaking with chills
    • Muscle pain/Body aches
    • 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 10 days are of greater intensity or frequency than what you normally experience.
  2. Have you had a positive COVID-19 test within the last 10 days?
  3. Have you had close contact with a confirmed or suspected case of COVID-19 case within 10 days?

  4. Are you currently awaiting results of a COVID-19 test?

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.
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