Covid Screening Form

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First Name

Last Name

Role

Anticipated Entry Point

Email Address (will receive link to status valid for 4 hours.)

Phone

1. To your knowledge, have you been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or had symptoms of COVID-19?

Yes

2. Have you tested positive for COVID-19 in the past 14 days?

Yes

3. Have you experienced any symptoms of COVID-19 in the past 14 days?

fever over 100 degrees
shortness of breath or difficulty breathing
chills and/or muscle ache
dry cough
sore throat
loss of taste or smell
confusion
blueish face or lips

Yes

4. Have you traveled outside the United States or to any state outside of New York State or those states contiguous to New York State (Pennsylvania, New Jersey, Connecticut, Massachusetts, or Vermont) in the past 10 days?

Yes