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
Submit
Should be Empty: