Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters.

Pembroke CSD COVID-19 Self Check Assessment

The safety of the employees, students, families, clients, partners and visitors remains Pembroke CSD's top priority. As the COVID-19 outbreak continues, we will closely monitor the situation and will periodically update our guidance based on current recommendations from New York State. If you are concerned about underlying medical conditions, please consult with your personal medical health care provider.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce, we are conducting a simple screening.

Your participation is important to help us take precautionary measures to protect you and everyone in this facility. We request you complete this screening everyday prior to entering our facility. Based on your response, you will be informed if you should report to work or if you can enter our facilities.

(This question is mandatory)

Please enter your First Name:

(This question is mandatory)

Please enter your Last Name:

(This question is mandatory)

Please enter your Email Address:

(This question is mandatory)

Choose the role that best describes you:

(This question is mandatory)

Which location will you be working at or visiting today?

(This question is mandatory)

Are one or more of the following statements true for you?

  • Within the past 10 days, I tested positive for COVID-19.
  • Within the past 10 days, I was knowingly within 6 feet of someone diagnosed with or suspected of having COVID-19 for more than 10 consecutive minutes without preventive measures.
  • Within the last 24 hours, I had a temperature equal to or greater than 100.0 °F and/or any COVID-19 symptoms that are new or not usual symptoms for me and are not related to seasonal allergies.
  • Within the past 10 days, I have returned from international travel.


***Visitors: Please keep the page open after submitting so you can show the results at the door.***

***Faculty and Staff: If you receive a red check mark after submitting this form, please contact your supervisor immediately.***

The data collected in this survey will be secured according to the Wayne-Finger Lakes BOCES Data Privacy and Security Policy as well as all pertinent data privacy laws and regulations. The data collected will exclusively be used for purposes that ensure the safety of the component districts of both Wayne-Finger Lakes and Genesee Valley BOCES employees and students.