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A 2-year Program for Young Adults with Intellectual Disabilities

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Home
Learn More
Contact & Apply
Academics
Residential
Events
- Register: Online Information Session
- Student Events Calendar
Donate

Return to Dorm Form for Students

This form must be completed when student returns to their dorm from travel and before entry.

If you answer ‘yes’ to any of the following statements, please contact Kevin Baker BEFORE entering the dorm. If your temperature is 100 degrees or higher, you will not be permitted to return to the dorm this day.
Name*
First Last
Residence
Date*
MM
DD
YYYY
Time*

: HH

MM
1. Have you had close contact with any persons under investigation/diagnosed with COVID-19 WITHOUT wearing Personal Protective Gear in the past 14 days?*
“Close contact” means within 6 feet of the person for at least 10 minutes.
- Yes
- No
2. Have you traveled outside of the country in the past 14 days?*
- Yes
- No
3. Do you have any of the following symptoms (cough, sore throat, fever, loss of smell or taste, shortness of breath, headache, or diarrhea)?*
- Yes
- No
4. Everyone entering this facility needs to take their own temperature every day. When you took your temperature today, was your temperature 100˚ or over?*
- Yes
- No
5. In the past 14 days, have you been out of state for more than 24 hours?*
- Yes
- No
6. If you have traveled internationally or to any state (other than those listed above) in the past 14 days, have you taken a COVID test within three days of returning back to NYS with a negative reading?*
- Yes
- No
7. Have you a COVID-19 test in the last few days?*
A recent COVID-19 test is required before reentering your dorm. If you have taken a test but do not yet have your results, you must wear a face mask at all times until your test result comes back negative.
- Yes
- No
Date of most recent COVID-19 test*
MM
DD
YYYY
Location of most recent COVID-19 test*
Results of most recent COVID-19 test*
- I tested negative
- I am still awaiting my test results
- I tested positive for the virus
REMEMBER: You must wear a mask at ALL TIMES, except when in your bedroom, while waiting for the results of your COVID-19 test.
Signature*
By signing above I am acknowledging that I have filled the form out accurately.
You must complete and sign this form before gaining entry to your dorm.

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