Student Health Prescreening Attestation


All students must conduct this health self-screen daily before entering the school

Do you currently have (or have had in the last 10 days) one or more of these new or worsening symptoms?

A temperature equal to or above 100 degrees F; Feel feverish or have chills; Cough; Loss of taste or smell; Fatigue/feeling of tiredness; Sore throat; Shortness of breath or trouble breathing; Nausea, vomiting or diarrhea; Muscle pain or body aches; Headaches; or Nasal congestion/runny nose.

In the past 10 days, have you tested positive for COVID-19 or have you been tested for COVID-19 and you are still waiting for the result?

In the last 14 days, have you been designated a contact of a person who tested positive for COVID-19 by a local health department?

In the last 14 days, have you traveled internationally to a CDC Level 2 or 3 COVID-19 related travel health notice country; or traveled to a state or territory on the New York State Travel Advisory List?

Further information on the list of states subject to the travel advisory can be found at https://coronavirus.health.ny.gov/covid-19-travel-advisory

Student First Name

Student Last Name

Birthdate (mm/dd/yy)

[v1018]