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School or Facility You're Entering
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Fill Out Daily Screening
Have you experienced 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?
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
(not a blood test)
that was your first positive result OR was AFTER 90 days from your previous positive result?
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 for their first time or who has been told they have symptoms of COVID-19? Clinical staff who were in appropriate PPE are not considered close contacts in these scenarios
Have you traveled to a state other than New Jersey, Pennsylvania, Connecticut, Massachusetts, or Vermont, OR internationally in the last 14 days?
Yes, for less than 24 hours, and I took or will take a COVID test on the 4th day after my arrival in New York.
Yes, for more than 24 hours, and I took a COVID test within 72 hours PRIOR to my arrival in New York, quarantined for at least three days upon my arrival in New York, and took a second COVID test on the 4th day AFTER my arrival.
Yes, and I am not in the two categories above.
This Health Screening is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a medical condition. Health screening results will be reviewed for the sole purpose of gaining access to facilities and confidentiality will be maintained.
Download a printable version of this questionnaire