Covid-19 Survey

Covid-19 Survey
Name *

First Name Last Name
Email *
example@example.com
Session Date you are submitting this for: *

Month Day Year
Date
Today's Date

Month Day Year
Date
Have you knowingly been in close contact in the past 14 days with anyone who has tested positive forCOVID-19 or who has or had symptoms of COVID-19? *

Yes No
Have you tested positive for COVID-19 through a diagnostic test in the past 14 days? *

Yes No
Have you experienced any symptoms of COVID-19 in the past 14 days? *

Yes No
Have you traveled within a state with significant community spread* of COVID-19 for longer than 24 hours within the past 14 days? *

Yes No
Should be Empty: