COVID-19 Health Screening Attestation

The New York State Department of Health Interim Guidance for Child Care Programs requires all individuals to complete a daily health screening questionnaire before arriving to a child care program or upon arrival to a child care program.

If an individual answers “Yes” to any of the screening questions,  they cannot enter the child care program, except as otherwise indicated.

Screening Questions:

  1. Is your temperature higher than or equal to 101 degrees Fahrenheit?
  2. Have you had any known close or proximate contact with a person confirmed (by diagnostic test) or suspected (based on symptoms) to have COVID-19 in the past 10 days? Note: Close contact is defined by DOH as being within 6 feet of an individual for 10 minutes or more within a 24-hour period, starting from 2 days before symptom onset or, if asymptomatic, 2 days before the date the positive sample was collected through when they are isolated. Close contact does not include individuals who work in a health care setting wearing appropriate, required personal protective equipment.

Exception:  Asymptomatic staff and children may attend if the staff/child is fully vaccinated or has recovered from laboratory confirmed COVID-19 in the previous 3 months and has not been placed on quarantine. Note:  Fully vaccinated is defined as being 2 weeks or more after either receipt of the second dose in a 2 dose vaccine series, or 2 weeks or more after receipt of one dose of a single-dose vaccine.

  1. Are you currently experiencing or have you recently, (within the past 10 days) experienced ANY COVID-19 symptoms?

Note:  Symptoms may occur with pre-existing medical conditions, such as allergies or migraines.  You should only answer "Yes" if your symptoms are new or worsening.

  • Cough
  • Shortness of breath
  • Trouble breathing
  • Fever (equal to or above 101 degrees Fahrenheit)
  • Chills
  • Muscle pain or body aches
  • Headache
  • Sore throat
  • Loss of taste or smell
  • Fatigue
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea
  1. Have you tested positive for COVID-19 through a diagnostic test within the past 10 days?
  2. Have you traveled within the past 10 days and not complied with requirements of the New York State Travel Advisory?
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