Staff Covid-19 Screening Survey

Staff Covid-19 Screening Survey

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Staff Covid-19 Screening Survey

If you answer is yes to any of the questions on the survey, please do not come to the NYADI campus. Notify your supervisor immediately for further instructions

Employee Name*
Date*
MM slash DD slash YYYY
Have you had any COVID-19 symptoms in past 14 days?*
Have you been tested positive for COVID-19 in past 14 days?*
Have you had any close contact with a confirmed or suspected COVID-19 case in the past 14 days?*
CAPTCHA
Consent*
By clicking this box you provide express written consent indicating a willingness for us to call you. We will never share your information.*
Consent*
By clicking this box you provide express written consent to contact you via SMS no more than 2-4 times/month. Standard messaging and data rates apply. Text STOP to opt-out at anytime.*
Name
This field is for validation purposes and should be left unchanged.

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800-906-8086

Staff Covid-19 Screening Survey

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