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User Role

Household

Name*

First Last

Date

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Health screening for...*

Staff
Student
Vendor/Guest

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

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

This individual cannot, go to school today. They must stay in isolation (at home and away from others)until the test results are back and are negative OR if positive, the local health department has released them from isolation.

In the last 14 days, has this individual:*

• Traveled internationally to a CDC level 2 or 3 COVID-19 related travel health notice country; or
• Traveled to a state or territory on the NYS Travel Advisory List; or
• Been designated a contact of a person who tested positive for COVID-19 by a local health department?

No
Yes

This individual cannot, go to school today. They must stay at home until your local health department releases this individual from quarantine, at least 14 days. A negative diagnostic COVID-19 test does not change the 14-day quarantine requirement.

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