Self Screening Declaration
Do you have a temperature over 100?
YES
NO
Are you feeling unwell today?
YES
NO
Have you had any symptoms of COVID-19 within the last 48 hours?
YES
NO
Have you knowingly been in close contact with anyone with symptoms of COVID-19 within the last 48 hours?
YES
NO
Have you been medically directed to self-quarantine due to possible exposure to COVID-19?
YES
NO
I have read and agree to the mitigation guidelines.
YES
NO
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Signature
*
Clear
Submit
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