COVID-19 Screening Form Step 1 of 250%To prevent the spread of COVID-19 and reduce the potential risk of exposure to everyone who enters the building, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time. This is in accordance of recommendation of the New York State Health Department and the Center for Communicable DiseasesName* First Last Place(s) in Building*Meeting With*Personal Phone Number (mobile/home)*Email* In the last 14 days have you experienced a fever, chills, unusual fatigue, body aches, muscle aches?*YesNoIn the last 14 days have you experienced a sore throat, runny nose, cough, or shortness of breath?*YesNoIn the last 14 days have you experienced abdominal pain, vomiting or diarrhea?*YesNoIn the last 14 days have you experienced change in your sense of smell or taste?*YesNoHave you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*YesNoIn the last 14 days, have you traveled outside of the tri-state area?*YesNoWhere have you traveled to?Although we are taking all necessary precautions to keep this facility COVID free, we do not recommend that people with underlying conditions that make them more at risk for serious illness spend time in the building at this time. Are you aware of this recommendation and understand it?*YesNoConsent* Upon entering the building, I will use the thermal scanner mounted on the wall to take my temperature. If I have a temperature above 100 degrees the thermal scanner will flash yellow and say "height". If this happens, I will exit the building, inform my supervisor and seek appropriate care.Consent* I understand that by checking this box, I am providing my electronic signature.
