COVID-19 Mandated Screening Questionnaire for


In the interest of health, wellness and public safety daily health screenings are required to be completed DAILY by any employee, vendor or visitor entering a school facility. The district is requiring that students be screened daily as well. Please complete the following survey. If your response is "yes" to ANY of the below questions, Please DO NOT ENTER THE BUILDING until further notice, answers will be reviewed by the school nurse and district administration daily.


*All fields are required



School Name

First Name

Last Name


Phone Number

Reason for visit:

Have you knowingly been in close or proximate contact in the past 10 days with anyone who has tested positive for COVID-19? If you answered yes, and had a positive COVID-19 test in the past 90 days and/or are fully vaccinated, you must contact Sue Tropeano to get clearance to enter the building.
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



Nausea or vomiting


Muscle pain or body aches

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