SDNY COVID-19 Visitor Screening Form 05 27 21.pdf

SDNY COVID-19 Updated Visitor Screening Form

Visitor Name:

Visitor Contact Number:

Date of Visit:

Some questions ask if you “achieved full vaccination.” A person has “achieved full vaccination” when at least 2 weeks have passed since their second shot in a 2-dose vaccination series (Pfizer/Moderna) or their one shot in a 1 dose vaccination (Johnson & Johnson).

1. Within the past 14 days, have you tested positive for COVID-19, or been told by a health care provider to assume you have COVID-19 due to symptoms or other factors?

Yes No

2. Have you experienced any of the following symptoms within the past 3 days that are not explained by allergies or an underlying condition? Fever (100.4 degree or higher, without the use of fever-reducing medications) or chills, shortness of breath, extreme fatigue, nausea or vomiting, congestion, muscle or body aches, headache, sore throat, new loss of taste or smell, diarrhea?

Yes No

3. Within the past 14 days, have you had close contact with a person with COVID-19, during the period starting 48 hours before the onset of their symptoms or, if asymptomatic, the date that they took the COVID-19 test?

Note: Close contact is defined as being less than 6 feet apart for more than 15 cumulative minutes in a 24-hour period. If you have achieved full vaccination prior to the close contact, please answer “No.”

Yes No

4. Have you had close contact within the past 14 days with anyone experiencing any of the following symptoms that are not explained by allergies or an underlying condition? Fever (100.4 degree or higher, without the use of fever -reducing medications) or chills, shortness of breath, extreme fatigue, nausea or vomiting, congestion, muscle or body aches, headache, sore throat, new loss of taste or smell, diarrhea?

If you have achieved full vaccination prior to the close contact, please answer “No.”

Yes No

5. Do you live with someone who, in the past 14 days, has been instructed to quarantine due to close contact with an individual who tested positive for

COVID-19? If you have achieved full vaccination prior to the close contact, please answer “No.”

Yes No

6. Within the past 10 days, have you been outside of New York, New Jersey, Connecticut, Pennsylvania, Massachusetts or Vermont for more than 24 hours?

If you have achieved full vaccination more than 14 days ago, please answer “No.” If your answer is “Yes,” you must meet the Office’s test-out protocol for travelers.

Yes No Test Out Protocols - Must test negative on a COVID PCR diagnostic test* administered within two days prior to entry to the Office. Once you present proof of negative test in accordance with our protocol, you will be allowed entry.

*At home or mail in test are not acceptable.

7. Are you fully vaccinated? Please include proof of vaccination.

Yes No