EBOLA Student Attestation

VNSNY is committed to the safety and well-being of our employees and patients / members. Please
immediately complete this attestation, which allows us to screen all students affiliated with VNSNY for Ebola Viral Disease(EVD) risk. Please answer the following two questions.
Name: 


A red asterisk (*) indicates required questions.

  1. Do you or anyone with whom you have had close contact have symptoms of a fever of > 100.4F or > 38C or report feeling feverish or have headache, muscle pain, weakness, diarrhea, vomiting, abdominal (stomach) pain and/or unexplained bleeding or bruising?*
    Yes
    No


  1. Do you or anyone with whom you have had close contact traveled to any of the following three West African countries in the last 21 days: Guinea, Sierra Leone or Liberia?*
    Yes
    No


  1. If you answered:
     NO to both symptoms and travel question (within 21 days to Sierra Leone, Liberia or Guinea):
    o Proceed with patient/member encounter or visit.
     YES to symptoms question but NO to travel question (to Sierra Leone, Liberia or Guinea):
    o Proceed with patient/member encounter or visit. Follow procedure for notification of a change in patient condition or assessment.
     YES to travel question (within 21 days to Sierra Leone, Liberia or Guinea) but NO to symptoms question:
    o Call the VNSNY RISK Hotline Immediately at 212-609-RISK (7475) and they will conference you in with a manager and the NYCDOHMH. **DO NOT LEAVE A VOICE MAIL, MUST SPEAK TO A LIVE PERSON**
     YES to both questions:
    o Call the VNSNY RISK Hotline Immediately at 212-609-RISK (7475) and they will conference you in with a manager and the NYCDOHMH. **DO NOT LEAVE A VOICE MAIL, MUST SPEAK TO A LIVE PERSON**
    Thank you for answering the VNSNY Ebola Screening and Attestation. As an affiliated student, you perform critically important work in community health for patients, members, and families. In the future, if your answer to the VNSNY Ebola Screening and Attestation changes to YES, contact the VNSNY Risk Hotline 212-609-7475 immediately.

    Please enter the date (MM/DD/YYYY):*


  1. Please enter your school:*


  1. Please type your full first and last name:
    This will serve as an electronic signature attesting that you read and understand this information.*





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