Health Screening Self-Assessment

* - Required

Badge Number *




1. Have you experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, or shortness of breath within the past 10 days? *


2. In the past 10 days, have you tested positive for COVID-19 using a test that tested saliva or used a nose or throat swab (not a blood test)? (10 days measured from the date you were tested, not the date you received the test result.) *


3. To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone while they had COVID-19? *


4. In the past 14 days, have you traveled to a country or state identified by New York State as having widespread community transmission of COVID-19 (other than just passing through the restricted state for less than 24 hours)? *


Visit for applicable states.

Please check the following statement before submitting. *