Daily Covid-19 Screening Questionnaire

All employees, vendors and clients must fill out this mandatory form prior to entering any P.O.R. Products facility. This must be done every day and will be subject to review.

If you have been exposed to the virus that causes Covid-19 or are showing symptoms, do NOT attempt to enter P.O.R. Products facilities. Fill out the form and call 914-636-0700 ext. 116 for further instructions.

All fields are required

First name

Last name

Cell or contact number

Today's date

Have you experienced a fever of 100.4 degrees F or greater, a new cough, or shortness of breath within the past 10 days?

Yes

In the past 10 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab? (not a blood test)

Yes

To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone while they had COVID-19 or symptoms of COVID-19 (fever, cough, or shortness of breath).

Yes

Have you traveled to NYS from a state other than Pennsylvania, New Jersey, Connecticut, Massachusetts and Vermont, or traveled from another country in the last 14 days?

Yes

Your Signature (draw your signature in the box)

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