EduForm
 

COVID-19 Mandated Visitor Screening Questionnaire

Per guidance from the Governor's Office regarding Phase 4 - re-openings, mandatory daily health screenings are required to be completed DAILY by any employee, vendor or visitor entering a school facility. Please complete the following survey. If your response is "yes" to ANY of the below questions, DO NOT ENTER THE BUILDING until further notice, answers will be reviewed by the school nurse and district administration daily in order to ensure full compliance with the Governor's regulations.

 

*All fields are required

 

Name:   _________________________________________________________

Reason for visit:

Today's Date: ____________________________________________________

Have you traveled internationally or to one of the following states in the past 14 days: Alabama, Alaska, Arkansas, Arizona, California, Colorado, Delaware, Florida, Georgia, Guam, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming?  -> health.ny.gov

Yes

No

Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19?

Yes

No

Have you tested positive for COVID-19 in the past 14-days?

Yes

No

Please check your temperature. Is it 100.0 F degrees or GREATER? If so, do not enter the building. Thermometers are available at the main offices.

Yes

No

Cancel
P.O. Box 13314, Albany, NY 12212-3314 • 518.344.7022 • 518.344.7454 (fax) • 888.999.2554 (toll free) • www.edvistas.com