Volunteer COVID-19 Self Health Screening Questionnaire

1) Have you had any of the following symptoms in the last 24 hours? *

Yes

Sudden loss of taste or smell

Shortness of breath or difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

Yes

Fever (usually 100.4 or higher)

Chills

Cough

Muscle pain or body aches

Headache

Sore throat

Issues breathing or

Sudden Fatigue

If you answered “Yes” to question one, please DO NOT come to volunteer during your date/time. We will be glad to reschedule you at a later date.

2) In the last 14 days have you: *

Yes

Been in contact with someone who was diagnosed with COVID-19?

Been in close contact with someone who had COVID-19 symptoms ?

Traveled internationally or taken a cruise?

Or your immediate family members experience any changes to their your/their health?

If you answered “Yes” to any part of question two, please DO NOT come to volunteer during your date/time. We will be glad to reschdule you at a later date.

I certify to the best of my knowledge; this information is accurate.
Signature *

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Name *

First Name Last Name
Date *

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