Please complete the questionnaire below before visiting any Graham location. If your response is "yes" to any question, please know that you can not enter a Graham facility. In that case, we urge you not to go on site and  to speak with your program or department leadership. Thank you for taking this important step in helping to keep Graham safe and healthy!

Por favor, complete este cuestionario antes de visitar cualquier sitio de Graham. Si su respuesta es "sí" a cualquier pregunta, sepa que no puede ingresar a una instalación de Graham. En ese caso, le recomendamos que no vaya al sitio y hable con el liderazgo de su programa o departamento. ¡Gracias por dar este importante paso para ayudar a mantener a Graham seguro y saludable!

Tanpri ranpli kesyonè ki anba a anvan ou vizite nenpòt kote Graham. Si repons ou an se "wi" nan nenpòt kesyon, tanpri konnen ke ou pa ka antre nan yon etablisman Graham. Nan ka sa a, nou ankouraje ou pa ale sou sit ak pale ak pwogram ou oswa lidèchip depatman. Mèsi pou pran etap enpòtan sa a nan ede kenbe Graham an sekirite ak an sante!

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* 1. Please complete the requested information:

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* 2. What site are you planning to visit?

¿Qué sitio planeas visitar?

Ki sit ou planifye pou vizite?

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* 3. What date and time are you intending to go to the site?

¿A qué fecha y hora tiene la intención de ir al sitio?

Ki dat ak ki lè ou gen entansyon ale sou sit la?

Date
Time

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* 4. I am a Graham employee

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* 5. [For Graham Employees only/ Solo para empleados de Graham/ Pou Anplwaye Graham sèlman ]
I have received WRITTEN authorization to enter this site by the following Executive leader:

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* 6. I received WRITTEN authorization from the Executive leader indicated in the previous question on the following date:

Date
Time

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* 7. Have you or anyone in your household been diagnosed with COVID-19 in the last 14 days?

¿A usted o alguien de su hogar le han diagnosticado COVID-19 en los últimos 14 días?

Èske oumenm oswa nenpòt moun lakay ou te dyagnostike ak COVID-19 nan 14 dènye jou yo?

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* 8. Have you or anyone in your household had symptoms of a respiratory infection (e.g. cough, sore throat, fever, shortness of breath, loss of smell or taste) in the last 14 days?

¿Usted o alguien de su hogar ha tenido síntomas de una infección respiratoria (por ejemplo, tos, dolor de garganta, fiebre, dificultad para respirar, pérdida del olfato o del gusto) en los últimos 14 días?

Èske oumenm oswa nenpòt moun nan kay ou te gen sentòm enfeksyon respiratwa (tankou tous, gòj fè mal, lafyèv, souf kout, pèdi sant oswa gou) nan 14 dènye jou yo?

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* 9. Have you been exposed (closer than six feet with more than 15 minutes of contact) to someone who has been diagnosed or tested positive for the disease or has symptoms of the disease?

¿Ha estado expuesto (a menos de seis pies con más de 15 minutos de contacto) a alguien que haya sido diagnosticado o haya dado positivo en la prueba de la enfermedad o tenga síntomas de la enfermedad?

Èske ou te ekspoze (pi pre pase sis pye ki gen plis pase 15 minit kontak) ak yon moun ki te dyagnostike oswa teste pozitif pou maladi a oswa ki gen sentòm maladi a?

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* 10. Have you or anyone in your household been directed to self-isolate or self-quarantine by a medical professional?

¿Un profesional médico le ha indicado a usted oa alguien de su hogar que se aísle o se ponga en cuarentena?

Eske ou menm oswa nenpòt moun nan kay ou te resevwa yon direksyon medikal pou izole tèt ou oswa pou mete tèt ou nan karantèn pa yon pwofesyonèl medikal?

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* 11. Have you or anyone in your household traveled outside of the NYS, NJ, CT or PA region in the past 14 days?

¿Ha viajado usted o alguien de su hogar fuera de la región de NYS, NJ, CT o PA en los últimos 14 días?

Èske oumenm oswa nenpòt moun lakay ou vwayaje andeyò rejyon NYS, NJ, CT oswa PA nan 14 jou ki sot pase yo?

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