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About
Office Staff Covid 19 Form
Covid Form
Employee Name
(Required)
Employee Email
Have you traveled internationally or out of NY State within the last 14 days? *
No
If YES, please explain and indicate Country or State travelled to for more than 24 hours.
Please explain
If travelled to any states, other than New Jersey, Connecticut or Pennsylvania MUST provide COVID-19 test results done within 3 days of departure from the state and on day 4 of arrival to NY or quarantine for 14 days. If travelled internationally, MUST quarantine for 14 days upon arrival to NY.
Have you had contact with any Persons under Investigation (PUIs) for COVID-19 within the last 14 days, or with anyone with known COVID-19?
No
If Yes, Please explain
Please explain
Have you been diagnosed/tested/treated for COVID-19 or placed under voluntary or mandatory quarantine in the past 14 days?
No
If Yes, Please explain
Please explain
Do you currently have symptoms of Upper Respiratory Infection (fever, cough, shortness of breath, sore throat)?,
No
If Yes, Please explain
Please explain
If you answered YES to any questions, please request medical clearance prior to return to work and inform DPS
