Auxiliary Staff -

Health Screening

Mandatory Health Screening Questions

for Students, Staff, Vendors

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admin
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User Role
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Household
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Name*
First Last
Email
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Date
MM slash DD slash YYYY
Login to the Portal to access the rest of this form
Health screening for…*
- Staff
- Student
- Vendor/Guest
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Which Grades will you be in contact with?*
- 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
Select Student*
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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
Birthday
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?*
- No
- Yes
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In the last 10 days has this individual traveled to a NONCONTIGUOUS state?*
- No
- Yes
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How long was your visit*
- 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?*
- Yes
- No
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Have you received a Negative Covid-19 test within three (3) days prior to your return to NY?*
- Yes
- No
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Did you quarantine for 3 days upon returning?*
- Yes
- No
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Did you receive a negative test on day 4 of your return?*
- 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?*
- 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