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COVID-19 Screening Assessment Questionnaire For Court

  1. village seal - color

  2. Insert Today's Date

  3. Enter you scheduled court date

  4. Best number to contact you

  5. 1- Have you tested positive for COVID-19 in the past 14 days?*

  6. 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)*

  7. 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)?*

  8. 4- Have traveled outside the country, or traveled to another state on New York's COVID-19 travel advisory watchlist(see the link to the right) within the last two weeks?*

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

  10. This document will be electronically submitted to the Freeport Village Court.

  11. ** IF YOU HAVE ANSWERED “YES” TO ANY QUESTION, PLEASE DO NOT COME INTO THE COURT – PLEASE CONTACT THE COURT IMMEDIATELY AT (516)377-2329 – OPTION #1 TRAFFIC DEPARTMENT OR OPTION #2 PARKING DEPARTMENT FOR FURTHER INSTRUCTIONS – YOU WILL BE ADJOURNED TO A NEW DATE BY MAIL **

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