The New York State Senate Confidential Health Reporting Form

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.

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.