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User Role

Household

Name*

First Last

Email

Date

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Health screening for...*

Which Grades will you be in contact with?*

Select Student*

Student ID

Student Grade

Student Name Full

Student Name

First Last

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?*

Was the test result positive OR are you still waiting for the result?*

In the last 10 days has this individual traveled to a NONCONTIGUOUS state?*

How long was your visit*

Have you received a Negative Covid-19 test in the four (4) days since returning to NY?*

Have you received a Negative Covid-19 test within three (3) days prior to your return to NY?*

Did you quarantine for 3 days upon returning?*

Did you receive a negative test on day 4 of your return?*

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?*

Does this individual currently have (or has had in the last 10 days) one or more of these new or worsening symptoms?*

Symptom Total

In School Temperature Check