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.
Have you traveled abroad/out of state during 2020?
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?
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
Shortness of Breath
Persistent Pain in the Chest
Loss of sense of taste/smell
I acknowledge that the information I've given is accurate and complete.
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