Name *

First Name

Last Name

Phone *

(###)

###

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1. Have you experienced any of the following symptoms in the past 48 hours: *

Fever or chills, cough, shortness of breath / 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

2. Have you been in close physical contact in the last 14 days with anyone who is known to have laboratory-confirmed COVID-19? OR anyone who has any symptoms consistent with COVID-19? *

Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection).

YES

NO

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

YES

NO

4. Have you traveled in the past 10 days? *

Travel is defined as any trip that is overnight AND on public transportation (plane, train, bus, Uber, Lyft, cab, etc.) OR any trip that is overnight AND with people who are not in your household.

YES

NO

5. Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19? *

YES

NO

6. Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months? *

To be considered fully vaccinated, you must be 2+ weeks following receipt of the second dose in a 2-dose series or +2 weeks following receipt of one dose of a single-dose vaccine.

YES

NO

PREFER NOT TO ANSWER

I certify that my responses are true and correct *

Checking this box certifies my responses

Date *

MM

DD

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