Health Form

Participant's Name *

First Name

Last Name

Parent's Name *

First Name

Last Name

Fever *

Have you experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, or shortness of breath within the past 10 days? No. Go to the next question. Yes. No further screening is needed. The person may not report to the workplace.

No

Yes

Tested *

In the past 10 days, have you tested positive for COVID-19 using a test that tested saliva or used a nose or throat swab (not a blood test)? (10 days measured from the date you were tested, not the date you received the test result.) No. Go to the next question. Yes. No further screening is needed. The person may not report to the workplace.

No

Yes

Contact *

To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone while they had COVID-19? No. Go to the next question. Yes. No further screening is needed. The person may not report to the workplace.

No

Yes

Travel *

In the past 14 days, have you traveled internationally or returned from a state identified by New York State as having widespread community transmission of COVID-19 (other than just passing through the restricted state for less than 24 hours)? Visit https://coronavirus.health.ny.gov/covid-19-travel-advisory for applicable states. No. The person may report to the workplace. Yes. No further screening is needed. The person may not report to the workplace.

No

Yes