Coronavirus Self Declaration Form
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name
First Name
Last Name
Have you traveled abroad/out of state during 2022?
Yes
No
Name of the area(s) visited & dates of travel
Country, State, City
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
Yes
No
Your relationship with the people and your last contact date with them
Please state whether you've experienced with in the past two weeks, or are currently experiencing the following
Yes
No
Fever
Cough
Shortness of Breath
Persistent Pain in the Chest
Gastrointestinal Distress
Loss of sense of taste/smell
Headache/dizziness
Unusual Fatigue
I acknowledge that the information I've given is accurate and complete.
Date
-
Month
-
Day
Year
Date
Signature
Clear
Submit
Should be Empty:
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