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. Since your last day of work, or last visit here: Do you/your child currently have (or have had in the last 10 days) one or more of these new 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 14 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 contact of a person who tested positive for COVID-19 by a local health department?
  4. Have you traveled internationally or to any state which does not border New York State (NYS) in the past 10 days?  

     

    For travelers who were in another state for more than 24 hours:

    • Travelers must obtain a test within three days of departure from that state.
    • The traveler must, upon arrival in New York, quarantine for three days.On day 4 of their quarantine, the traveler must obtain another COVID test. If both tests comes back negative, the traveler may exit quarantine early upon receipt of the second negative diagnostic test.
     
    For travelers who were in another state for less than 24 hours:
    • The traveler does not need a test prior to their departure from the other state, and does not need to quarantine upon arrival in New York State.
    • However, the traveler must fill out our traveler form upon entry into New York State, and take a COVID diagnostic test 4 days after their arrival in New York


    health.ny.gov >

  5. If you are a student: Is there anyone in your household who is symptomatic?



I certify, to the best of my knowledge, that this information is accurate.


Parent/Guardian: If filling out this form on behalf of a student, please provide the student's first and last name.
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