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Health Screening
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Mandatory Health Screening Questions
for Students, Staff, Vendors
admin
User Role
Household
Name
*
First
Last
Email
Date
Date Format: MM slash DD slash YYYY
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Health screening for...
*
Staff
Student
Vendor/Guest
Which Grades will you be in contact with?
*
None
Nursery 2YR
Nursery 3YR
PreK
Kindergarten-Main
Kindergarten-Yurt
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Other
Select Student
*
Select
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
Date Format: MM slash DD slash YYYY
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
In the last 14 days have you traveled OUTSIDE the contiguous states to NY, meaning beyond Pennsylvania, New Jersey, Connecticut, Massachusetts and Vermont?
*
No
Yes
How long was your visit
*
Less than 24 hours
More than 24 hours
Have you received a Negative Covid-19 test in the four (4) days since returning to NY?
*
Yes
No
Have you received a Negative Covid-19 test within three (3) days prior to your return to NY?
*
Yes
No
Did you quarantine for 3 days upon returning?
*
Yes
No
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
Symptom Total
In School Temperature Check
Not taken
Normal
Has Tempature