Name: Email:

Date:

1. Have you experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, shortness of breath or other symptoms listed by the CDC within the past 48 hours? (CDC link for the full list of symptoms: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html)

2. Are you isolating or quarantining becasue you tested positive for COVID-19 via a PCR test or are worried that you may be sick with COVID-19?

3. Are you fully vaccinated OR have you recovered from a documented COVID-10 infection in the last 3 months? (To be considered fully vaccinated, you must be two or more weeks post receipt of the last dose of the vaccine.)

IMPORTANT: IF YOU ANSWERED "YES" TO QUESTION 3 and "NO" TO QUESTIONS 1 AND 2, PLEASE SKIP TO THE CERTIFICATION STEP BELOW.

4. Have you been in close contact in the last 14 days with anyone who is known to have laboratory-confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19 traveled outside of the Tristate? (Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a
cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset
(or, for asymptomatic individuals, 48 hours prior to test specimen collection).)

5. Are you currently waiting on the results of a PCR COVID-19 test? (Answer "No" if you are waiting for results of a pre-travel or post-travel COVID-19 test.)

6. If you travel outside of New York State, please visit https://coronavirus.health.ny.gov/covid-19-travel-advisory for current guidelines.

*

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