COVID Screening Questionnaire
The safety of our employees 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 workforce, we are asking employees who are physically present at their worksite to complete this questionnaire within the first hour of reporting to the workplace, then again during the second half of their shift.

If you answer yes to any questions (except if you have a mask), leave work immediately.  Please notify your supervisor and the Office of Human Resources for guidance at (607) 746-4753.
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Full Name *
Work Location *
Do you have a fever (above 100.3F)?                                 Please use the thermometer provided to take your temperature. *
Have you had any of the following COVID-19 symptoms within the past 14 days?                               Please check all that apply. *
Required
Have you tested positive for COVID-19 through a diagnostic test in the past 14 days? *
Have you had close contact with confirmed or suspected COVID-19 cases within the past 5 days? *
If unvaccinated or not boosted, do you have a mask in your possession available for immediate use? *
Initialing below attests that you are not experiencing any of the symptoms listed above. *
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