COVID-19 Screening

COVID-19 Screening
Name

First Name Last Name
Birth Date

Month Day Year
Have you had any of the following symptoms in the past 14 days?
Fever of 100.4°F (38°C) or greater?

No Yes
Please explain
Cough?

No Yes
Please explain
Shortness of breath?

No Yes
Please explain
Loss of taste or smell?

No Yes
Please explain
Travel Information
Have you traveled outside of the United States within the past 14 days?

No Yes
Country Visited
Layovers
Date returned to the US

Month Day Year
Date
Were you instructed to self-quarantine or self-monitor upon return to the US?

No Yes
Have any of your close contacts traveled outside of the US within the past 14 days?

No Yes
Please provide details
Signature

Clear
Should be Empty:

Have you had any of the following symptoms in the past 14 days?