New York State Office of Children and Family Services
CHILD CARE EMPLOYEE, CHILD, AND ESSENTIAL VISITORS HEALTH SCREENING ATTESTATION
Before entering a child care program, employees, parents (on behalf of children), and essential visitors must complete a daily health screening questionnaire. In addition, each employee, child’s parent, and essential visitor must sign and submit this form to the program. Employees, child(ren)’s parents, and essential visitors must answer all questions and take their temperature(s) daily to confirm a body temperature lower than 100.0°F. If anyone answers “Yes” to any of the questions below,
they cannot enter the child care program. A parent or guardian is responsible for completing the daily screening on behalf of their child(ren). Self-Screening: Below are the self-screening questions that employees, parents of child(ren), and essential visitors are required to answer daily. If any of the answers to the below questions are “Yes,” individuals cannot enter the program. If the answers are “No” to all the following questions, individuals
may enter the program. If employees, children’s parents, and essential visitors cannot take their temperature at home, but answer “No” to all other questions, they may report to the program to have their temperature taken on site.