CDC Mandatory Health Questionnaire

Are you a Staff, Student or Visitor? *

Is anyone in your household quarantining or have tested positive for COVID-19 within the past 14 days? *

Are you working Virtually (Working from Home)? *

Campus Location *

Frank J. Gargiulo Campus

Earl W. Byrd Center

Explore Middle School

Career Development Center (CDC)

Harrison Center

North Hudson Center

Date of Entry to Location *

Date

Please read the following statements and select your response from the drop down below.

Do you have a fever? ¿Tienes fiebre?
Do you have any respiratory symptoms? (coughing, sneezing, difficulty breathing?) ¿Tienes síntomas respiratorio?
Have you traveled out of the country or visited a state on the travel advisory list in the last 14 days? (not including NY and PA) * ¿Ha viajado fuera del país o ha visitado un estado en la lista de avisos de viaje en los últimos 14 días?

Response *

Your selection from the drop down above will automatically answer the three questions to complete the form.

Do you have a fever? *

¿Tienes fiebre?

Do you have any respiratory symptoms? (coughing, sneezing, difficulty breathing?) *

¿Tienes síntomas respiratorio?

Have you returned from international travel in the last 3 days? *

¿Ha regresado de un viaje internacional en los últimos 3 días?

The school nurse will receive an email for further evaluation if response of “Yes” to any of these questions are selected.

Full Name *

First Name Last Name

Email *

Please use your HCST email address if applicable.

Please make sure you also check your Spam or Junk mail for confirmation after submission.

Time

Hour Minutes

AM/PM Option