Health Screening - COVID-19 (Visitor)

To be completed prior to arriving on the SUNY Plattsburgh campus. Completing this health screening is just one measure our campus has implemented to prevent the spread of the COVID-19 and reduce the potential risk of exposure to our workforce.

You can visit the campus. A copy of this form has been sent to the email address provided from 'no-reply@plattsburgh.edu'. Please forward a copy of the screening to the party you are visiting.
DO NOT Come to SUNY Plattsburgh Campus or enter any buildings. Notify the party you were to meet.
Name Name First Last
Email
Local Address Local Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Primary Phone Number Primary Phone Number - ### - ### ####
Department /Location Being Visited
Time of Arrival Time of Arrival : HH MM AM/PM
In the past 14 days, have you knowingly been in close or proximate contact with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 within the past 14 days (and you are not fully vaccinated and have not tested positive for COVID-19 within the past 90 days)?

In the past 14 days, have you knowingly been in close or proximate contact with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 within the past 14 days (and you are not fully vaccinated and have not tested positive for COVID-19 within the past 90 days)? Yes No
Have you tested positive for COVID-19 in the past 14 days?

Have you tested positive for COVID-19 in the past 14 days? Yes No
Have you experienced any symptoms of COVID-19 (see below) in the past 14 days?

- Cough
- Shortness of breath or difficulty breathing
- Fever (over 100°F)
- Chills
- Muscle pain
- Sore throat
- New loss of taste or smell
- Unexplained fatigue
- Muscle pain or body aches
- Unexplained headache
- Runny nose or nasal congestion
- Unexplained nausea vomiting, or diarrhea

Note: If any of these symptoms are related to a pre-existing condition, check "No".

Have you experienced any symptoms of COVID-19 (see below) in the past 14 days?

- Cough
- Shortness of breath or difficulty breathing
- Fever (over 100°F)
- Chills
- Muscle pain
- Sore throat
- New loss of taste or smell
- Unexplained fatigue
- Muscle pain or body aches
- Unexplained headache
- Runny nose or nasal congestion
- Unexplained nausea vomiting, or diarrhea

Note: If any of these symptoms are related to a pre-existing condition, check "No". Yes No
In the last 10 days, have you returned from International travel (and you
are NOT fully vaccinated)?

In the last 10 days, have you returned from International travel (and you
are NOT fully vaccinated)? Yes (You must complete a NYS Traveler Health Form with the NYS DOH. Indicate your date of arrival in New York State in the Comments section on the next page, and whether you plan to complete a 10-day quarantine or "test out" per the new protocol.) No

Health Screening - COVID-19 (Visitor)

Health Screening - COVID-19 (Visitor)

You can visit the campus. A copy of this form has been sent to the email address provided from 'no-reply@plattsburgh.edu'. Please forward a copy of the screening to the party you are visiting.

DO NOT Come to SUNY Plattsburgh Campus or enter any buildings. Notify the party you were to meet.