Contact Tracing and Health Screen

Name *

First

Last

Date / Time Visiting this Facility *

Date

Time

Phone *

Temperature *

Please take temperature before arrival, or at temperature tablet on your way in.

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? *

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? *

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? *