Complete the visitor’s questionaire
Temperature check
Masks are optional
If you are sick, please do not come into the facility.
Please be aware that visitation policies can change at anytime.
Visiting Hours:
Monday - Friday: 8:00 AM - 8:00 PM
Saturday - Sunday: 10:00 A - 6:00 PM
ALL Visitors MUST fill out questionnaire in vehicle (as well as temperature check) before visitation can be approved by NWCI staff.
Please be advised that this information may be provided to NYS Dept. of Health for contact tracing and inspections.
Visitors must adhere to NYS Department of Health guidance and NWCI policies during visit.
*Visit Date _____/_____/______ *Time _____:00 AM/PM
*Name: First ______________________________________ Last: _________________________
*Home Address: Street ____________________________________ Town __________________
State ____________ Zip ________
*Phone number (day) ________________ (evening if different) ___________________
Email (if available) ________________________________
*COVID-19 Questionnaire
*Circle YES, NO, or N/A for each of the following questions*
1. In the past 14 days, have you had any symptoms (temperature over 100F, shortness of breath, new cough, change in cough, sore throat, chills, fatigue, chills, body aches, nausea, vomiting, diarrhea, loss of sense of smell or taste, ?) related to COVID-19? YES NO
2. In the past 14 days, have you had a positive COVID-19 test? YES NO
3. In the past 14 days, have you been in close contact with a confirmed/suspected COVID-19 case? YES NO
4. In the past 14 days, have you been exposed to a community setting/area with a rate higher than 10% or considered high risk per NYS or CDC alerts/guidance? YES NO
My signature affirms I have answered these questions to the fullest extent of my knowledge, and I agree to comply with all of NYS Dept. of Health and New Windsor Country Inn policies regarding visitation including but not limited to: proper mask usage, hand hygiene, maintaining distance of at least 6 feet, moving directly to and from visitation room and visit during the scheduled time to permit others the opportunity to visit.
Signature ________________________________________ Date ______________________
Staff Only:
Is visitor’s temperature (prior to entering building) under 100 degrees Fahrenheit? YES NO
Do you approve this visitation? YES NO
*If NO, notify the resident for the reason of denying approval of visit.