Screening Form

First Name *

Last Name *

Work Phone

Mobile Phone

Email Address *

Date

Do you presently have a fever, or had a fever in the last five days?YesNo

Do you have any of these symptoms: cough, difficulty breathing, sore throat, new loss of taste or smell?YesNo

Have you been in contact with any symptomatic, confirmed COVID-19 positive individuals in the last five days?YesNo

Have you tested positive for COVID-19 within the last five days?YesNo

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