Adult Program Event Health Screening Name * First Name Last Name Today's Date * MM DD YYYY Current Temperature: * New Symptoms (Not Otherwise Explained): * -Temperature Over 100.4°F -Chills -Cough -Shortness of Breath -Loss of Taste or Smell -Muscle Aches Yes No Over the past 14 days, have you: * Received a positive COVID-19 test? Yes No Over the past 14 days, have you: * Had contact with someone who had a confirmed or suspected case of COVID-19? Yes No Have you received a COVID-19 vaccine? * Yes No Travel: * Have you traveled to any restricted states listed on the NYS Travel Advisory website (https://coronavirus.health.ny.gov/covid-19-travel-advisory) in the past 14 days? Yes No I attest all of the information is true. * Thank you! Be well! *DO NOT COME TO THE OFFICE IF YOU REPORTED A TEMPERATURE OVER 100°F OR ANSWERED YES TO ANY OF THE ABOVE.*
