COVID-19 Employee Screening

This questionnaire must be completed DAILY by all HWS employees prior to their arrival on campus or entering a campus building. If you answer "Yes" to any of the questions below, please contact your supervisor immediately. If you start to feel sick during the work day, go home and contact your supervisor. Please direct all questions and concerns to Human Resources (315-781-3312).

* - required

Question 1

First name *

Question 2

Last Name *

Question 3

Department *

Question 4

Individual Type

Faculty
Staff
Student
Vendor
Visitor

Question 5

Where will you be working/access on campus today (list buildings & room #'s if possible)

Screening Questions

Question 6

Do you currently have a fever (temperature of 100.4 F or greater) without having taken any fever-reducing medications or that is not usual for you? *

Yes
No
Unable to measure

Question 7

Have you experienced any of the following COVID-19 related symptoms in the past 14 days: cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, or loss of taste or smell that is not usual for you? *

Question 8

Have you tested positive for COVID-19 in the past 14 days, or have you been instructed by a health care professional/public health official/contact tracing app to self-isolate or quarantine? *

Question 9

Have you knowingly been in close (within 6 feet) or proximate (same enclosed environment, such as an office, but greater than 6 feet) contact with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 within the past 14 days? *

Question 10

Have you, or anyone you live with, traveled outside New York State in the last 14 days? *

Question 11

If you answered YES to the question concerning travel outside New York State, please list the state(s) and duration of your stay below

Thank you for taking the wellness questionnaire. If you answered YES to having any symptoms or having been exposed to COVID-19 do not report to work and contact your supervisor immediately. All others should report to work as normally scheduled.

Acknowledgement

By clicking NEXT on this screening form, I acknowledge that I have answered the questions on this survey truthfully and that I have completed the COVID-19 Safety Training.