New York Employee Daily Office Entry Health Check Question Title * 1. Date Date / Time Date Time AM/PM - AM PM Question Title * 2. Employee Name Question Title * 3. Have you experienced any symptoms of COVID-19, including a fever of 100.0 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath that started in the past 10 days? No Yes, and I have received a lab-confirmed negative result from a COVID-19 diagnostic test (not a blood test) since the onset of symptoms AND have not had symptoms for at least 24 hours. Yes, and I am not in the category above. (If this is your selection, do not report to the office.) Question Title * 4. In the past 10 days, have you received a positive result from a COVID-19 diagnostic test (not a blood test). Please note that 10 days is measured from the day you were tested, not from the day when you got the test result. No Yes (If this is your selection, do not report to the office.) Question Title * 5. Have you had close contact (or proximate contact as determined by healthauthorities) in the past 10 days with any person confirmed by diagnostic test, or suspected based on symptoms, to have COVID-19? No Yes, but I am considered fully vaccinated. Yes, and I am not considered fully vaccinated. (If this is your selection, do not report to the office.) Done