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Covid Screen/Contract Tracing Form
In adherence to state law, kindly fill out this form each time you visit the facility.
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Name
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First
Last
Date / Time Visiting this Facility
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Date
Time
Phone
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Temperature
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Please take temperature before arrival, or at temperature tablet on your way in.
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Have you experienced any symptoms of COVID-19, including a fever of 100.0 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath within the past 10 days?
*
No
Yes, and I have received a negative result from a COVID-19 test since the onset of symptoms AND have not had symptoms for at least 24 hours.
Yes, and I am not in the category above.
In the past 10 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab?
*
Yes
No
To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone who tested positive for COVID-19 or who has or had symptoms of COVID-19?
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Yes
No
Have you traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days?
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Yes
No
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