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Covid Screening Form

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First Name

Last Name

Role

Anticipated Entry Point

Name of Host

Name of Company

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

a. Have you isolated for at least 10 days?

Yes

b. Are you asymptomatic?

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 Internationally in the past 10 days?

Yes

5. Please enter the date you most recently returned to New York State

6. If any of the below scenarios describe your actions since returning to the U.S., please select Yes.

I was outside of the U.S. and I have quarantined for a full 10 days after my return.
I was outside of the U.S. and quarantined for 7 days with a negative PCR test 3-5 days after my return

Yes

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