Health Screening
Mandatory Health Screening Questions
for Students, Staff, Vendors
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User Role
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Household
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Name
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First
Last
Email
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Date
MM slash DD slash YYYY
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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
Select Student
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Select
– Fill Out Other Fields –
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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
Month
1
2
3
4
5
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9
10
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Day
1
2
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Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1934
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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?
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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 Tuesday
Jun 28, 2022
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1) Re-enrollment Contract
2) Family Registration
3) Health Form
4) Media Release
5) Communications Form
6) Add Skills Form
7) School District
8) COVID-19 Community Pledge
10) Bus Transportation Requests (optional)
Menu
1) Re-enrollment Contract
2) Family Registration
3) Health Form
4) Media Release
5) Communications Form
6) Add Skills Form
7) School District
8) COVID-19 Community Pledge
10) Bus Transportation Requests (optional)
2022/23 Bus Request form
You must fill out a separate form for each student.
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Household
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School Year
2022/2023
2021/2022
2020/2021
2019/2020
School District
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Kingston
New Paltz
Rondout Valley
Onteora
Email
*
Date
MM slash DD slash YYYY
Student Name
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Student Name
*
First
Last
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Student ID
Street Address
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Street Address
Address Line 2
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Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address
Same as previous
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Angola
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Antarctica
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Virgin Islands, U.S.
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Country
Student Age
*
Date of birth
*
MM slash DD slash YYYY
Grade Level in September 2021
*
School requesting Transportation to
*
School attended by your child in the
2022/2023
School year
*
Student Ethnicity (choose one):
I – American Indian or Native America
W – White
B – Black or African American
P – Native American or other Pacific Islander
H – Hispanic or Latino
A – Asian
Student lives with
Both Parents
Father
Mother
Legal Guardian
Step‐Parent
Parent/Guardian Name
*
First
Last
Parent/Guardian Relation to Student
Parent/Guardian Home Phone
*
Parent/Guardian Cell Phone
*
Parent/Guardian Name 2 (if applicable)
First
Last
Parent/Guardian 2 Home Phone
Parent/Guardian 2 Cell Phone
Signature of Parent/Guardian
*
Emergency Contacts (Provide at least 2)
*
Click "+" to add additional contact(s)
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Address
Relation to Student
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