Name *

First Name

Last Name

Symptoms *

In the last 48 hours, have you had any of these symptoms that are not caused by another condition?

Fever or chills

Cough

Shortness of breath

Fatigue

Muscle or body aches

Headache

Loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

None of the above

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 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 you 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

Have you traveled outside the country in the last 14 days? *

Yes

No