BFC Partners BFC Daily Health Screening Questionnaire

Date*

Name*

First

Last

1. Before coming into the office today, I checked my temperature and it is currently less than 100.4° F (38.0° C).*

Yes
No

2. Have you, or anyone in your household, experienced any of the following COVID-19 symptoms within the last 14 days?*

Cough*
Shortness of breath or difficulty breathing
Fever – 100.4° F (38.0° C) or more
Chills
Muscle pain
Sore throat
New loss of taste or smell
Gastrointestinal symptoms such as nausea, vomiting or diarrhea

*Note: Coughing (or other symptoms) that are related to seasonal allergies are not considered symptoms of COVID-19.

Yes
No

3. Have you tested positive for COVID-19 within the last 14 days?*

Yes
No

4. Have you had close contact with any individual who is a confirmed or suspected COVID-19 case within the last 14 days?*

Yes
No

5. Have you traveled to a state that has a high positive test rate (greater than ten (10) per 100,000 residents, or higher than a 10% positivity rate, over a seven-day rolling average) in accordance with New York State Executive Order No. 205?*

Yes
No