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

 

Reason for visit:

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?  Please check restricted states on health.ny.gov.  Please check international countries that are Level 2 and Level 3 restricted https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html.

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?

Yes

No

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?

 

Yes

No

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