Health Screening
Mandatory Health Screening Questions
for Students, Staff, Vendors
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Household
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Name
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Date
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Health screening for…
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Staff
Student
Vendor/Guest
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Which Grades will you be in contact with?
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None
Nursery 2s
Nursery 3s
PreK
Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Other
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Student ID
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Student Grade
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Student Name Full
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Student Name
First
Last
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Status
Company if Vendor | Grade if Substitute
Vendor or Guest Name
First
Last
Vendor or Guest Email
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In the past 10 days, this individual has been tested for the virus that causes COVID-19, also known as SARS-CoV-2?
*
No
Yes
Was the test result positive OR are you still waiting for the result?
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No
Yes
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In the last 10 days has this individual traveled to a NONCONTIGUOUS state?
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No
Yes
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How long was your visit
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Less than 24 hours
More than 24 hours
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Have you received a Negative Covid-19 test in the four (4) days since returning to NY?
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Yes
No
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Have you received a Negative Covid-19 test within three (3) days prior to your return to NY?
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Yes
No
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Did you quarantine for 3 days upon returning?
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Yes
No
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Did you receive a negative test on day 4 of your return?
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Yes
No
In the last 14 days, has this individual been designated in contact of a person who tested positive for COVID-19 by a local health department?
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No
Yes
Does this individual currently have (or has 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
Feel feverish
or have chills
Cough
Loss of taste
or smell
Fatigue/feeling
of tiredness
Sore throat
Shortness of breath
or trouble breathing
Nausea, vomiting, diarrhea
Muscle pain
or body aches
Headaches
Nasal congestion/runny nose
No Symptoms
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Symptom Total
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In School Temperature Check
Not taken
Normal
Has Temperature
Today is Sunday
Jun 26, 2022
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