Daily COVID-19 Employee Questionnaire

**Fully vaccinated employees (2 weeks post last vaccine) are not required to complete this questionnaire.

The safety of our employees, customers, families and visitors remain Achieve Beyond's top priority. Achieve Beyond continues to monitor the situation closely and will periodically update company guidance based on current recommendations from the Centers for Disease Control and Prevention (CDC).

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce, we are conducting a simple daily screening questionnaire. Your participation is required daily (if unvaccinated/not two weeks post vaccination) prior to entering the office and is important to help us take precautionary measures to protect your fellow employees and visitors.

Please note for unvaccinated employees, you are required to wear a facemask in all common areas of the office and to abide by social distancing of a minimum of six feet.

Full Name:(*)

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Which office are you working in?(*)




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1) Have you experienced any cold or flu-like symptoms in the last 10 days (to include fever, cough, sore throat, muscle fatigue, headaches, respiratory illness, or difficulty breathing?(*)


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If yes, please explain in comment box:

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2) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 10 days?(*)


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3) If you travelled internationally, and have not recovered from COVID-19 in the past 3 months, have you been tested 3-5 days after arrival in New York?(*)



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4) Have you been fully vaccinated AND two weeks have passed since your second dose of the Pfizer or Moderna vaccine or two weeks have passed since receiving the Johnson and Johnson vaccine?(*)


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* Please note if you have domestically travelled and returned to NYS, you still need to monitor your health for possible symptoms for 14 days.








Please note that your responses will be forward to the Human Resources department. If you answered yes to any of the above questions, please contact HR immediately at This email address is being protected from spambots. You need JavaScript enabled to view it. to discuss.