COVID-19 Screening Attestation

The safety of the employees, students, families, clients, partners and visitors remains our top priority. As the COVID-19 outbreak continues, we will closely monitor the situation and will periodically update our guidance based document on current recommendations from New York State.

Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions (e.g. serious heart disease, chronic lung disease or asthma, immunocompromised state, severe liver disease, etc.) might be at higher risk for severe illness from COVID-19. If you are concerned about underlying medical conditions, please consult with your personal medical health care provider.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce, we are conducting a simple screening. Your participation is important to help us take precautionary measures to protect you and everyone in this facility. We request you complete this screening everyday prior to entering a facility. Based on your response, you will be informed if you should report to work or if you can enter our facilities.

This is not a substitute for professional medical advice, diagnosis, or treatment of disease or other conditions, including COVID-19. Always consult a medical professional if you have questions, are experiencing symptoms or if you have an emergency.

*All fields are required

Have you had any of these symptoms?

• Fever >100° 
• Chills 
• Shortness of breath or difficulty breathing 
• New cough 
• New loss of taste or smell 
• Fatigue 
• Muscle or body aches 
• Headache 
• Sore Throat 
• Congestion or runny nose 
• Nausea, Vomiting or Diarrhea

Note: Answer “yes” if the symptoms you have experienced in the last 14 days are of greater intensity or frequency than what you normally experience.

Have you tested positive for COVID-19 in the past 10-days?

Have you been designated by the Department of Health and/or school as a contact of a person who tested Positive for Covid-19?

Note:  If you were notified by your workplace or DOH that you are a true contact, you should be quarantining for 10 days.  

Are you/ and/or Household Members (siblings, parents, grandparents) awaiting Covid -19 test results due to exposure and/or symptoms?

Note: If you have answered yes, please remain home until test results are received.