EMPLOYEE / VISITOR COVID-19 Screening Form

EMPLOYEE / VISITOR COVID-19 Screening Form

  • The screening questionnaire must be completed by any employees or visitors BEFORE they enter Trocaire College or in the front lobby of the main campus.
  • COMPLETE THIS FORM, PRIOR TO ENTERING THE BUILDING, ONLY IF YOU WILL BE COMING ONTO TROCAIRE'S CAMPUS TODAY
  • Prior to entering Trocaire College, please complete this form by checking Yes or No in response to the following questions related to your recent history and how you are feeling today:

  • 2.) Have you experienced any symptoms* of COVID-19 in the past 14 days (See list below):
  • *Note: COVID-19 Symptoms include:
    Fever or chillsCough
    Shortness of breath or difficulty breathingFatigue
    Muscle or body achesHeadache
    New loss of taste or smellSore throat
    Congestion or runny noseNausea or vomiting
    Diarrhea

  • New York State now has travel restrictions, requiring individuals to undergo quarantine if they traveled out of the country or out of state.**

    **Note: The list of states currently under travel quarantine by New York is found here (Click Here for New York’s list of travel-restricted states)

  • Please answer the following questions related to recent travel and/or need to quarantine:

  • 4). Since June 24, 2020 have you traveled out of state or to any other location that requires you to be quarantined for 14 days upon your return to New York?**
  • 5). Have you come in contact with anyone who has traveled to travel-restricted locations over the same period of time?**
  • If you responded yes to any of these questions, do not enter the campus and please contact your President's Council member
  • If, at any time, your response to the questions above changes, please contact your President's Council member.

  • Using the drop-down listing below, please choose the department to which you want your form sent.

  • Date Format: MM slash DD slash YYYY