First Name
Last Name
1. Have you tested positive for COVID-19 in the past 14 days?
Yes
No
2. Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19?
(Check "No" if you have recovered from a known case of COVID-19 in the last 3 months OR if you received all required doses of the COVID-19 vaccine to be fully vaccinated.)
Yes
No
3. Have you experienced any of the following symptoms of COVID-19 in the past 14 days: cough, shortness of breath or difficulty breathing, fever of 100 degrees or higher, chills, muscle pain, sore throat, new loss of taste or smell?
Yes
No
Please answer all questions.