COVID-19 Safety Check

Written by Admin on January 18, 2022. Posted in Uncategorized.

Name *

First

Last

Email *

1. I have or had within the past 72 hours a fever of 100.4 degrees or higher. *

• Yes
• No

2. I have or had within the past 72 hours a cough and/or sore throat. *

• Yes
• No

3. I currently have or had within the past 72 hours shortness of breath. *

• Yes
• No

4. I have or had within the past 72 hours COVID-19 symptoms (e.g., loss of taste or smell, chills, muscle pain, stomach problems, nausea, diarrhea, or vomiting). *

• Yes
• No

5. I have or had within the past 72 hours close contact with an individual diagnosed or exhibiting symptoms of COVID-19. *

• Yes
• No

6. I have received a positive test result or diagnosis based on symptoms for COVID-19. *

• Yes
• No

7. I have been directed to self-isolate or quarantine by a health care provider or public health official. *

• Yes
• No

8. I have returned from travel to a foreign country within the past 30 days. *

• Yes
• No

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