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Staff Covid-19 Health Check-In

Please fill out the form below for Daily temperature screening and to assist DOH officials in event of contact tracing.


Staff Covid-19 Health Check-In
Name
Mobile Number
Have you tested positive through a diagnostic test for COVID-19 in the past 14days?
Yes
No
Have you experienced any symptoms of COVID-19, including a temperature of greater than 100.00 degrees Fahrenheit in the past 14 days?
Yes
No
Have you traveled internationally or from a state with a widespread community transmission of COVID-19 per the New York Travel Advisory in the past 14 days?
Yes
No
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 or who has or had symptoms of COVID-19?
Yes
No
Unsure
Position
Teacher
Assistant Teacher
Teachers Aide
Therapist
Administration
Consultant
Visitor
Administrative Staff