Please submit this before arriving.  We will take your temperature (touchless) upon arrival

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* 1. Student Name:

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* 2. Today's Date

Date
Time

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* 3. Class you are attending

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* 4. Have you experienced any symptoms* of COVID-19 in the past 14 days?
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

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* 5. Have you tested positive for COVID-19 in the past 14 days?

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* 6. Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has symptoms* of COVID-19?

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* 7. Have you recently traveled to a restricted area that is under a Level 2, 3, or 4 Travel Advisory according to the U.S. State Department**? https://wwwnc.cdc.gov/travel/notices

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* 8. Have you recently traveled to a currently restricted state*** under NYS Department of Health? https://coronavirus.health.ny.gov/covid-19-travel-advisory

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