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COVID-19 DAILY Screening Assessment Questionnaire

  1. village seal - color

  2. Insert Today's Date

  3. 1- Have you tested positive for COVID-19 in the past 14 days?*

  4. 2- Have you experienced symptoms of COVID-19 in the past 14 days? (symptoms include, but are not limited to: cough, shortness of breath or difficulty breathing, fever, chills. muscle pain, sore throat, or new loss of taste and/or smell)*

  5. 3- Have you been in close contact, in the past 14 days, with anyone who has tested positive for COVID-19 (within the last 14 days) or who has or had symptoms of COVID-19 (within the past 14 days)?*

  6. 4- Have you traveled outside of the State of New York in the Last fourteen (14) days?*

  7. Signature: I hereby affirm that to the best of my knowledge , all answers above are true.

  8. This document will be electronically submitted to Human Resources.

  9. Leave This Blank:

  10. This field is not part of the form submission.