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CLBS Health Screening Questionnaire
Please fill this survey out daily for the 2 weeks before your arrival at CLBS/Ranger School. If any of your answers to any of these questions are “YES,” please inform the CLBS Business Manager immediately via email at
CLBS@esf.edu
.
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* Indicates required question
Email
*
Your email
First/Last Name:
*
Your answer
Phone Number:
*
Your answer
Do you have a fever > 100.4° F?
*
Yes
No
Have you had COVID-like symptoms (cough, shortness of breath, fever, chills, muscle pain, sore throat, loss of taste/smell) in the last 14 days NOT due to a known health condition?
*
Yes
No
Have you had close contact with confirmed or suspected COVID-19 cases in the last 14 days?
*
Yes
No
Have you been in contact with anyone outside your immediate household unit without wearing a mask and without social distancing?
*
Yes
No
Have you travelled outside of New York to a non-contiguous state, OR will you be arriving from a non-contiguous state? *If yes, please check the New York Travel Advisory and comply with any instructions: (
https://coronavirus.health.ny.gov/covid-19-travel-advisory)*
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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