STUDENT QUESTIONNAIRE

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What is your name? *

What is today's date? *

YYYY

DO YOU CURRENTLY HAVE COVID-19 and have not yet been released from isolation/quarantine and cleared to return to school? *

Yes

DO YOU HAVE ANY OF THE FOLLOWING NEW SYMPTOMS THAT ARE NOT EXPLAINED BY ANY MEDICAL CONDITION YOU ALREADY HAVE: Cough, shortness of breath, difficulty breathing, or at least two of the following symptoms: Fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell? *

Yes

OVER THE PAST 14 DAYS: Has anyone you have been in contact with had possible or confirmed COVID-19? *

Yes

OVER THE PAST 14 DAYS: Have you returned from international travel? *

Yes

OVER THE PAST 14 DAYS: Have you returned from international travel or from a state that is on the NYS Mandatory Quarantine List? *

Yes

Are you fully vaccinated? *

Yes

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