Ulster County Community College PROD

To comply with NYS Standards all employees, students and visitors must complete the following questionnaire before entering campus each day.

* - Required

First Name*:
Last Name:*:
Date of Birth:*:
Phone Number (XXX-XXX-XXXX format)*:

Have you experienced any of the following symptoms in the last 14 days?*

• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

Yes

No

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Have you tested positive for COVID-19 in the last 10 days?*

Yes

No

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Have you had close or proximate contact with confirmed or suspected COVID-19 case in the past 14 days?*

Yes

No

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