Daily COVID-19 Screening Attestation

(Please read below first, then answer these questions and press "SUBMIT" button below.)

   I.  Please Select Your Role:   

  II.  Select Yes or No To All Symptom Questions Below: 

          

 III.  I am doing my part to keep myself and others safe and I am

       following the practices outlined in our COVID-19 and NYS safety protocols.

     Please Agree Here:     

  IV. Enter First Name:   

   V.  Enter Last Name:  

         VI.  Enter E-Mail:   

    VII. Enter Phone #:    

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.
 

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 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 with a confirmed or suspected case of COVID-19 case within 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 in the past 14 days?