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COVID-19 DAILY Screening Assessment
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Employee / Contractor First Name
Employee / Contractor Last Name
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Phone Number or Extension
1- Have you tested positive for COVID-19 in the past 14 days?
2- Have you experienced symptoms of COVID-19 in the past 14 days? (symptoms include, but are not limited to: cough, shortness of breath or difficulty breathing, fever, chills. muscle pain, sore throat, or new loss of taste and/or smell)
3- Have you been in close contact, in the past 14 days, with anyone who has tested positive for COVID-19 (within the last 14 days) or who has or had symptoms of COVID-19 (within the past 14 days)?
4- Have you traveled outside of the State of New York in the Last fourteen (14) days?
Signature: I hereby affirm that to the best of my knowledge , all answers above are true.
First Last Name
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