Fillable COVID-19 Attestation Form Student Self-Declaration (Clinton Community College)

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COVID-19 Attestation Form Student Self-Declaration (Clinton Community College)

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COVID-19 Attestation
Form
Student Self-Declaration
We are asking ALL students to begin tracking their health and completing the below attestation form. Commuting
students will be expected to submit this form electronically to the Dean of Student Affairs, John Borner at
john.borner@clinton.edu
As a reminder, all students entering New York State from another state must complete the online New York State
traveler form upon entering New York. Failing to do so may carry fines up to $10,000 from New York State.
Student Name: Date:
Place of Ordinary Residence:
Telephone #:
1. Are you familiar with information and guidance on the coronavirus (COVID-19), including
standard health protection measures and precautions?
Yes / No
2. Do you understand and have you complied with applicable standard health protection
measures and precautions to prevent the spread of the coronavirus (COVID-19), such
as wearing of face coverings, proper hand washing, coughing etiquette, appropriate
social distancing?
Yes / No
3. By your signature below, do you attest to having properly completed a 14 -day
precautionary self-quarantine in accordance with all guidance prior to arriving on
campus?
Yes/No
If "Yes", please explain the circumstances and the length of self -quarantine:
Not properly completing a 14-day self-quarantine puts you and others at risk of not being
able to continue in their program of study.
4. During the last 14 days, have you:
- Tested positive for being infected with the coronavirus (COVID-19)?
Yes / No
If "Yes", please provide date of test and name of test:
- Tested positive for the antibodies for the coronavirus (COVID-19)?
Yes / No
If "Yes", please provide date of test and name of test:
- Shown any symptoms associated with the coronavirus (COVID-19), specifically,
New and continuous cough: Yes / No
Fever: Yes / No
Loss of smell or taste: Yes / No
Shortness of breath/difficulty breathing: Yes / No
- Had close contact with anyone that has tested positive for coronavirus
(COVID-19)?
("Close contact" means being at a distance of less than six feet/two meters for more than 15 minutes.)
Yes / No
- Had close contact with anyone with symptoms of the coronavirus (COVID-19)?
("Close contact" means being at a distance of less than six feet/two for more than 15 minutes.)
Yes / No
- Maintained good personal hygiene and complied with applicable health
protection measures and precautions?
Yes / No
- Have you traveled INTERNATIONALLY?
Yes / No
- Have you travelled DOMESTICALLY in the last fourteen days to a restricted
state on the New York State Travel Advisory? (Click on link to see list of
restricted states if you are unsure)
Yes / No
I confirm that the information provided above is correct to the best of my knowledge.
Signature: Date: ____________________
Source: SUNY Maritime 2020
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COVID-19 Attestation Form Student Self-Declaration (Clinton Community College)

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Completed 29 January 2021

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