Name *

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Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nasea or vomiting diarrrhea. *

• Yes
• No

Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has symptoms consistent with COVID-19? *

• Yes
• No

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? *

• Yes
• No

Are you currently waiting on the results of a COVID-19 test? *

• Yes
• No

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