COVID-19 Screening Form
In order to maintain the health and safety of you and our community, please submit the form below at least 24 hours prior to visiting campus.We ask that you do not come to campus if you have any symptoms or would answer YES to any of the questions below.
In the past 14 days have you had the following...
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
None of the above
Have you had a positive COVID-19 test in the past 14 days?
Yes
No
In the past 14 days, have you had close or proximate contact with a confirmed or suspected COVID-19 case in the past 14 days?
Yes
No
Have you traveled to a COVID-19 hotspot or spent more than 24 hours in a Restricted State within the last 14 days?
Yes
No
View Restricted States as determined by New York.
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: