EduForm
 

COVID-19 Mandated Screening Questionnaire for

Visitors

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

 

Reason for visit:

Have you traveled to a CDC level 2 or level 3 health notice country or to states other than New Jersey, Connecticut, Vermont, Massachusetts or Pennsylvania within the past 10 days? If yes, please refer to the New York State Department of Health COVID-19 Travel Advisory

Have you knowingly been in close or proximate contact in the past 10 days with anyone who has tested positive for COVID-19?
Have you tested positive for COVID-19 in the past 10-days?
Please check your temperature. Is it 100.0 F degrees or GREATER?

Have you experienced any of the following symptoms in the past 48 hours: Fever or chills, Loss of taste or smell, Shortness of breath, Cough, Congestion or runny nose, Sore throat, Fatigue, Headache, Nausea or vomiting, Diarrhea, Muscle pain or body aches?

 

If you answered 'yes' to the above question, check all the symptoms that apply:

Fever or chills

Loss of taste or smell

Shortness of breath

Cough,congestion or runny nose

Sore throat

Fatigue

Headache

Nausea or vomiting

Diarrhea

Muscle pain or body aches

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