NNYSA COVID-19 Screening
If you have any of these symptoms or said yes to any of the questions below, please stay home. Contact Jessie Bahr jessie@nnysa.org or 610-451-7399 to notify her of any issues or exposure.
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
 Phone number *
Position *
Required
Location *
Have you experienced any of the following *
Required
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have a confirmed case of COVID-19 or with anyone who has any symptoms consistent with COVID-19? *
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? *
Are you currently waiting on the results of a COVID-19 test? *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy