Form
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Are you experiencing any COVID -19 symptoms?
NO
YES
Do you have a fever?
NO
YES
Do you have a cough, muscle pain, chills, headache, recent loss of smell or taste, or sore throat?
NO
YES
Have you been in another state on the CT Travel Ban list since your last check in? If yes please notify your Program Coordinator immediately.
NO
YES
Submit
Should be Empty: