COVID-19 Employee/Student/Visitor Daily Health-Screening Questionnaire

Employee/Student/Visitor Name:  ____________________________________________

Supervisor’s Name:  _____________________________________________________

This Screening Tool is offered for informational purposes to help you check for COVID-19 symptoms as outlined by the NYS Department of Health.  If you answer yes to any question, please do not come to school. Please contact your supervisor or the attendance office. Please contact your health professional, share your answers to the questions below, and request a COVID-19 test. You will need lab results and a statement from your health professional to return to school or work.  

This is not a substitute for professional medical advice, diagnosis, or treatment of disease or other conditions, including COVID-19. Always consult a medical professional for serious symptoms or call 911 for emergencies.

QuestionsYesNo
1.   Have you knowingly been in close or proximate contact in the past 14- days with anyone who has tested positive through a diagnostic test for COVID-19?_______________/_______________
2.   Have you tested positive through a diagnostic test for COVID-19 in the past 14-days  _______________/_______________
3.    Are you experiencing any symptoms of COVID-19, such as: Fever >100°F or chills; Cough; Shortness of breath or difficulty breathing; Fatigue; Muscle or body aches; Headache; Loss of taste or smell; Sore throat; Congestion or runny nose; Nausea or vomiting; Diarrhea?

*Check “No” if the nature of the symptom (duration, intensity, etc.)  is consistent with a pre-existing condition of which you are already aware that is not new, worsening, or different from its usual presentation. (i.e., seasonal allergies, asthma, sinus, tension or migraine headaches, inflammatory bowel disease, Crohn’s Disease, Lactose Intolerance, Irritable Bowel Disease, Chronic Fatigue Syndrome).  
_______________/_______________
4.   Have you traveled internationally or from a state with widespread community transmission of COVID-19 per New York State Travel Advisory in the past 14-days https://coronavirus.health.ny.gov/covid-19-travel-advisory  _______________/_______________

Revised  9/22/2020