The New York State Senate Confidential Health Reporting Form

March 13, 2020

I acknowledge that I have read and understood the questions below. I have answered truthfully to the best of my ability and I affirm the accuracy of the answers I have given. I understand that New York State Senate, the New York State Department of Health and the Centers for Disease Control and Prevention are relying on the truth and accuracy of my responses.

First & Last Name

Assigned Senate office/department

Email Address

Have you tested positive for the coronavirus disease (COVID-19)?

If yes, please specify the date

Were you exposed to anyone with COVID-19?

If yes, please specify the approximate date

Have you been fully vaccinated against COVID-19?

Have you been boosted?

Have you been ill or under self-isolation because of exposure to COVID-19?

If yes, please specify the beginning date

Have you been directed to self-quarantine because of exposure to COVID-19?

If yes, please specify the Beginning Date

Have you had a fever in the last 24 hours?

Have you experienced shortness of breath or difficulty breathing?

During your period of self-isolation or quarantine were you exposed to anyone with COVID-19?

If yes, please specify the location(s)

Please specify the approximate date

I acknowledge that I have read and understood the questions above. I have answered truthfully to the best of my ability and I affirm the accuracy of the answers I have given. I understand that New York State Senate, the New York State Department of Health and the Centers for Disease Control and Prevention are relying on the truth and accuracy of my responses.

I Acknowledge

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