Daily Screening Form (COVID-19)

Daily Screening Form (COVID-19)
The safety of our faculty, staff, and students is our overriding priority. We are following the guidance from the NYS Department of Health and the CDC. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our Community, we are asking employees and students who are physically present at the College to complete this questionnaire within the first hour of reporting to the workplace or being in the building.
We strongly encourage you to complete this form prior to your arrival.

This form should be completed daily.

* Required
Date *

Month Day Year
Date
Name *

First Last
Email *
jsmith@sunyopt.edu
Department
Student (Year)
Screening Questions: Please answer Yes or No to each question.

If you answer Yes to question 1 to 4, leave work immediately. If you answered Yes to question #5, please contact your supervisor or Student Affairs. Students should contact the Office of Student Affairs (212-938-5500). Employees should notify their supervisor and the Office of Human Resources for guidance (212-938-5883).
1. Do you have a fever (above 100°F)? *

YES NO
2. Are you currently experiencing any of the following symptoms that you cannot attribute to another health condition? *

YES NO
- Cough (new or worsening)
- Headache (new or worsening)
- Shortness of Breath (new or worsening)
- Chills or Fever
- Congestion or Running Nose
- Sore Throat (new or worsening)
- New Loss of Taste or Smell
- Muscle or Body aches
- Nausea or Vomiting
- Fatigue
- Diarrhea
3. Have you tested positive for COVID-19 in the past 10 days? *

YES NO
4. Have you had any known close or proximate contact with anyone confirmed or suspected to have COVID-19 in the past 10 days? *

YES NO
5. Have you recently (within the past 10 days) traveled to New York City from an International location or from a state, listed as a Restricted State on the NYS Travel Advisory (https://coronavirus.health.ny.gov/covid-19-travel-advisory) ? *

YES NO
I certify that the information provided herein is true and correct to the best of my knowledge. *
(Initial)
Please verify that you are human *
Should be Empty: