COVID-19 Health Screening

Your Name*

Name*

First Last

Company Name*

Email*

Phone*

Have you experienced any of the following?*

Been identified by any health department, or health care provider as a close contact (within 6 feet for at least 15 minutes) with anyone diagnosed with COVID-19 in the last 14 days?
Been advised by any health department, or health care provider to stay home or quarantine for today?
Tested positive for COVID-19 in the last 10 days, or has anyone in the household tested positive for COVID-19 in the last 14 days?
Been advised by any health department, or health care provider to test for COVID-19 within the past 14 days and results are pending?
Had any of these symptoms or has any member of the household has these symptoms, that are new and not attributed to allergies or a pre-existing condition: Fever 100.4 F or higher, new onset of moderate to severe headache, shortness of breath, new cough, sore throat, vomiting, diarrhea, abdominal pain from unknown cause, new congestions/runny nose, new loss of taste or smell, nausea, fatigue from unknown cause, muscle or body aches.
Traveled internationally within the last 10 days?
NONE OF THE ABOVE

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