Mandatory Health Screening Questions for Students, Staff, Vendors Hiddenadmin HiddenUser Role HiddenHousehold HiddenName* First Last Email HiddenDate MM slash DD slash YYYY Login to the Portal to access the rest of this formHealth screening for...* Staff Student Vendor/Guest HiddenWhich 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*Select– Fill Out Other Fields –HiddenStudent ID HiddenStudent Grade HiddenStudent Name Full HiddenStudent Name First Last HiddenStatus Company if Vendor | Grade if Substitute Vendor or Guest Name First Last Vendor or Guest Email BirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920In 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 HiddenIn the last 10 days has this individual traveled to a NONCONTIGUOUS state?* No Yes HiddenHow long was your visit* Less than 24 hours More than 24 hours HiddenHave you received a Negative Covid-19 test in the four (4) days since returning to NY?* Yes No HiddenHave you received a Negative Covid-19 test within three (3) days prior to your return to NY?* Yes No HiddenDid you quarantine for 3 days upon returning?* Yes No HiddenDid 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 temperaturegreater than orequal to 100.0° F Feel feverishor have chills Cough Loss of tasteor smell Fatigue/feelingof tiredness Sore throat Shortness of breathor trouble breathing Nausea, vomiting, diarrhea Muscle painor body aches Headaches Nasal congestion/runny nose No Symptoms HiddenSymptom TotalHiddenIn School Temperature Check Not taken Normal Has Temperature
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