NCSY Pre-Event Covid Screening Tool
5/27 Latte & Learning
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Cell Phone *
Email *
1. In the last 14 days, have you been diagnosed with Coronavirus/COVID 19 *
2. In the last 14 days, have you been tested for Coronavirus/COVID 19? *
3. If YES, what type of test did you take?
Clear selection
4. If YES, what was the result of this test?
Clear selection
5. In the last 14 days, has anyone in your immediate household (relative, roommate) been tested for or diagnosed with coronavirus/COVID 19? *
6. In the last 14 days, have you been in close contact (within 6 feet for longer than 10 minutes) with someone who tested positive or was diagnosed with Coronavirus, or is awaiting test results? *
7. In the last 14 days, have you been in close contact with anyone experiencing fever, cough or who appeared ill? *
8. In the last 14 days, have you traveled outside of the New York, New Jersey, or Connecticut area to another state identified under the NYS travel advisory ttps://coronavirus.health.ny.gov/covid-19-travel-advisory or internationally identified under the CDC advisory ( https://www.cdc.gov/travel/notices/)? *
9. In the last 14 days, have you developed any of these symptoms? *
Yes
No
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, vomiting or diarrhea
* if you answered any of the questions with a response that has a * near it, you may NOT attend this event.
** If you answer yes to taking a rapid test due to a known exposure or symptoms If the answer was because of known exposure or symptoms, they should not attend any events until after they take a PCR test or it has been 14 days since exposure/symptoms.  Rapid tests are unreliable.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of NCSY. Report Abuse
Google Forms