First name:

Last name:

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1. Temperature...

  • Is your temperature above 100.0°F today?

2. In the past 14 days, have you...

  • tested positive for COVID-19?
  • been designated a contact of a person who tested positive for COVID-19 by a local health department?
  • experienced any of these new or worsening symptoms of COVID-19?
    • Fever ≥ 100°F or chills
    • New cough
    • Shortness of breath or difficulty breathing
    • Fatigue
    • Headache
    • Muscle or body aches
    • Sore throat
    • New loss of taste and/or smell
    • Nausea, vomiting, or diarrhea
    • Congestion or runny nose
  • been advised to stay home by a medical professional due to COVID-19 concerns?