(Please read below first, then
answer these questions and press "SUBMIT"
I. Please Select Your Role:
II. Select Yes or No To All Symptom Questions Below:
NO To ALL symptom questions
YES to ANY one (or More) of the symptom questions
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.
IV. Enter First Name:
V. Enter Last Name:
VII. Enter Phone #:
The safety of the employees, students, families, clients, partners and
visitors remains our top priority. As the COVID-19 outbreak continues,
will closely monitor the situation and will periodically update our
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
severe illness from COVID-19. If you are concerned about
conditions, please consult with your personal
medical health care provider.
To prevent the spread of COVID-19 and reduce the potential risk of
to our workforce, we are conducting a simple screening.
is important to help us take precautionary measures to
protect you and
everyone in this facility. We request you complete this
prior to entering a facility. Based on your response,
you will be informed
if you should report to work or if you can enter
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)
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)
if the symptoms you have experienced in the last 14 days are of
intensity or frequency than what you normally
2. Have you had a positive COVID
3. Have you had close contact with a confirmed or suspected case of
4. Have you traveled internationally or from a state with
widespread community transmission