Visitors COVID-19 Daily Screening Form

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This questionnaire must be completed daily by all staff and visitors once per day before or immediately after entering any building in the Newfane Central School District. Please note that you are required to disclose any changes to your answers immediately to your supervisor.

First Name *

Last Name *

Which NCSD buildings will you be entering today? *

Newfane Central Services

Newfane Early Childhood Center

Newfane Elementary School

Newfane Learning Center

Newfane Middle School

Newfane High School

Athletic Fields/working with athletes

Required

Please check all that apply. *

* A listing of COVID-19 symptoms can be accessed at the link below to the Centers for Disease Control and Prevention website. For purposes of the third statement below, having been in close contact means having been within six feet of the person for at least ten minutes, starting from 48 hours before the infected person had symptoms.LINK TO SYMPTOMS https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html NY Travel advisory information can be found at: https://coronavirus.health.ny.gov/covid-19-travel-advisory

1. I have tested positive through a diagnostic test for COVID-19 in the past 14 days.

2. I have had a fever (temperature exceeding 100.0°), cough, shortness of breath, new loss of taste or smell, or one or more other COVID-19 symptoms within the past 14 days. *

3. I have been in close contact in the past 14 days with someone whom I know has tested positive through a diagnostic test for COVID-19 or who has or had symptoms of COVID-19. *

4. I have traveled internationally or spent time in a state that constitutes a restricted travel area under Governor's Executive Order 205.3

5. None of the above.

Required

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