Employee wellness check-in

*If you answered YES to any of these questions, please notify your supervisor immediately.
Do not proceed to work.


    1. Is your temperature currently 100 degrees or higher? (required)
    Note: If you do not have a thermometer, you can complete your screening in-person at the workplace.

    NoYesWill check at library

    2. Have you been in close contact with a confirmed case of COVID-19? (required)

    NoYes

    3. Are you experiencing a cough, shortness of breath or a sore throat? (required)

    NoYes

    4. Have you had a fever in the last 48 hours? (required)

    NoYes

    5. Have you had a new loss of taste or smell? (required)

    NoYes

    6. Have you had vomiting or diarrhea in the last 24 hours? (required)

    NoYes

    Note for questions 3-6: A few of the above symptoms may occur with pre-existing medical conditions, such as allergies. You should answer “yes” if your symptoms are new or worsening.
    7. Have you traveled out of state, to a non-contiguous state(s), for more than or less than 24 hours? (required)

    NoYes

    If you answered "No" to question 7, PLEASE SUBMIT YOUR FORM NOW.

    If you answered "Yes" and your time there exceeded 24 hours:

    Do not come to work; mandatory quarantine for 14 days. Complete the Traveler Health Form. Contact your supervisor. If you wish to "test out" of a mandatory 14-day quarantine, you must have a COVID diagnostic test within 3 days of departure from the state you visited, quarantine upon arrival in NYS, and on day 4 of quarantine secure a COVID diagnostic test and complete the Traveler Health Form. If both tests are negative, you may return to work. If you have not followed the "test out" protocol, do not come to work, plan to quarantine for 14 days and contact your supervisor.


    If you answered "Yes" and your time there was less than 24 hours:

    Stay home, do not report to work. Complete the Traveler Health Form. Contact your supervisor. Have a COVID diagnostic test 4 days after your arrival in NYS. If the test is negative, you may return to work.


    *All entries are true and correct. I attest by submitting this form that I have followed County and State travel guidelines.
    PLEASE SUBMIT YOUR FORM NOW.

    *Guidelines and Traveler Health Forms are set forth by the Governor NYS Department of Health and are available through the link below.

    Click here for New York State travel guidelines and Traveler Health Form.

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