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