• Name
  • Date
    MM slash DD slash YYYY
  • Type
  • Within the last 14 days, have you tested positive for COVID19 or been asked to self-isolate/quarantine by a health care professional or public health official?
  • Within the last 14 days, have you been in close contact with anyone who has tested positive for COVID19 or shown any symptoms of COVID19?
  • Within the last 14 days, have you experienced a fever measured above 100.4 degrees?
  • Within the last 14 days, have you experienced any of the following cold or flu like symptoms: cough, shortness of breath or difficulty breathing, pain or pressure in chest, chills, muscle pain, sore throat, diarrhea, extreme fatigue, new loss of taste or smell?
  • Signature - I attest that the foregoing information is true and correct