Name:

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
• nausea or vomiting
• diarrhea

Yes No

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with:

• Anyone who is known to have laboratory-confirmed COVID-19?
• Anyone who has any 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