EMPLOYEE DOCUMENTATION OF COVID-19 TEST RESULTS

Name Name * First Middle Last
Date of Birth Date of Birth / MM / DD YYYY
Email *
Phone Phone * - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
In which county do you reside?

In which county do you reside? Orange Ulster Sullivan Dutchess Rockland Westchester Pike (PA) Sussex (NJ) Other
Date of COVID-19 test? Date of COVID-19 test? * / MM / DD YYYY
Location where test was performed (name of physican's office, hospital, testing site, etc.): *
COVID-19 test results: *

COVID-19 test results: Positive Negative
Please upload your COVID-19 test results: *

Attach Files
Do you have any symptoms? *

Do you have any symptoms? Yes No
Were you told to quarantine? *

Were you told to quarantine? Yes No
How long were you told to quarantine? *
What date did your quarantine begin? What date did your quarantine begin? * / MM / DD YYYY
Were you exposed to someone who tested positive for COVID-19? *

Were you exposed to someone who tested positive for COVID-19? Yes No I don't know
How are you teaching/working? *

How are you teaching/working? On campus On-line/Remote Both
Have any members of your family tested positive? *

Have any members of your family tested positive? Yes No
Draw your signature into the box below.

Draw or Type

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Full Name

I understand this is a legal representation of my signature.