COVID-19 Safety Questionnaire 

Name *

First Name

Last Name

Have you traveled outside the country, or traveled to another state on New York’s COVID-19 travel advisory watchlist (see above) within the last two weeks? *

Yes

No

Do you reside or have you had close contact with anyone who has been outside the country or in a State on the advisory watchlist within the last two weeks? *

Yes

No

Have you been directed to quarantine, isolate or self-monitor at home for the coronavirus by any doctor, hospital or health agency within the last two weeks? *

Yes

No

Have you been diagnosed with, or have had close contact with anyone diagnosed with, COVID-19 within the last two weeks? *

Yes

No

Do you have flu-like symptoms (including cough, shortness of breath, fever (100°F. or higher), chills, headache) *

Yes

No