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:

In the past 10 days, have you/your child traveled internationally to a CDC level 2 or 3 COVID-19 related travel health notice country; OR have you traveled to any state other than Vermont, Massachusetts, Connecticut, Pennsylvania or New Jersey?


Have you/your child traveled to or lived in an area where the local, Tribal, territorial, or state health department is reporting large numbers of COVID-19 cases as described in the Community Mitigation Framework?

Have you/your child knowingly been in close or proximate contact as defined by CDC recommendations in the past 10 days with anyone who has tested positive for COVID-19? 

In the past 10 days, have you/your child tested positive for COVID-19 OR are you waiting for a COVID-19 test result?

Do you/your child currently have (or have had in the last 10 days) one or more of these new or worsening symptoms?



• A temperature greater than or equal to 100.0° F (37.8° C)
• Shortness of breath or trouble breathing
• Feel feverish or have chills • Nausea, vomiting, diarrhea
• Cough
• Muscle pain or body aches
• Loss of taste or smell • Headaches
• Fatigue/feeling of tiredness • Nasal congestion/runny nose
• Sore throat  
Building Access
P.O. Box 13314, Albany, NY 12212-3314 • 518.344.7022 • 518.344.7454 (fax) • 888.999.2554 (toll free) •