IMI Building Check-in (NO-PHONE)
Name
*
First Name
Last Name
Date
*
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Year
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Minutes
AM
PM
AM/PM Option
1.) Have you been within 6 feet of a person with a confirmed case of COVID-19 in the past 14 days?
*
Yes
No
1a.) Has anyone in your household been advised to self quarantine?
*
Yes
No
2.) In the last 48 hours, have you had any of the following NEW symptoms?
2a.) Fever of 100.5 F (38 C) or above?
*
Yes
No
2b.) Fever symptoms like chills or sweating, or repeated shaking with chills?
*
Yes
No
2c.) Trouble breathing, shortness of breath or severe wheezing?
*
Yes
No
2d.) Cough?
*
Yes
No
2e.) Muscle aches?
*
Yes
No
2f.) Sore throat?
*
Yes
No
2g.) Loss of smell or taste, or a change in taste?
*
Yes
No
2h.) Nausea, vomiting or diarrhea?
*
Yes
No
2i.) Headache?
*
Yes
No
3.) Are you having any unexpected new symptoms?
*
Yes
No
4.) Have you traveled in the past 14 days?
*
Yes
No
Signature
Submit
Should be Empty: