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.


*Field is required


Reason for visit:

Have you traveled outside of NYS but not completed the NYS Travel Advisory?  -> 

Have you traveled internationally to a Covid-19 High Risk area (CDC level risk 2 or 3) and not completed the Covid-19 travel requirement? -> 
In the last 10 days have you or someone residing in your household tested positive for Covid-19?
In the last 10 days have you been considered a direct contact of someone who was diagnosed with Covid-19?

In the last 10 days have you had new or worsening of the following symptoms?


Temperature greater than 100 degrees F Shortness of breath or trouble breathing
Feel feverish or have chills Nausea, vomiting or diarrhea
Cough Headaches
Lost of taste or smell Nasal congestion or runny nose
Feel fatigued or tired Muscle aches and/or joint pain
Sore throat  

Are you awaiting Covid-19 test results?

I certify to the best of my knowledge; this information is accurate.

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