COVID-19 Attestation Form

Employee ID Number:*

If you are not sure what your Employee ID number is, it can be found on your badge (if you have one) and on Greenshades.

In the past week, did you/were you:

Have you had a fever?*

Travel via a plane?*

Travel to a State identified as a State with significant community spread of COVID-19?*

To view the current list of restricted states, please visit: NYS Travel Restrictions List

I have visited a nursing home, hospital, or correctional facility.*

Test positive to COVID19?*

Reside with anyone who tested positive to COVID19?*

Exposed to anyone who tested positive to COVID19?*

Placed in quarantine by a medical provider?*

Placed in quarantine by the Department of Health?*

In the last seven days have you had a fever, cough, shortness of breath, loss of taste or smell or other flu like symptoms?*

If you answered yes to the question above, what was the date you last had a fever, cough or shortness of breath?