Covid 19 Screening

Covid-19 Screening Questionnaire
Name *
Email *
example@example.com
Which of the following best describes your role at Macungie Ambulance Corps? *

Member Student Visitor / Other
Temperature (°F) *
Have you been diagnosed with Covid-19 in the past 14 days? *

Yes No
Are you living with someone who has been diagnosed with COVID-19 in the past 14 days? *

Yes No
Have you had unprotected contact with anybody diagnosed with COVID-19 in the past 14 days? *

Yes No
Have you been outside Pennsylvania in the past 14 days? *

Yes No
What date did your return to Pennsylvania? *

Month Day Year
Date
Since your return to Pennsylvania, have you received a negative Covid-19 test? *

Yes No
Have you had any of the following symptoms in the past 72 hours? (If not, leave blank)

Fever or Chills Cough Shortness of breath, or difficulty breathing Extreme Fatigue Muscle or Body aches Unusual or atypical headache New loss of taste or smell Sore Throat Congestion or runny nose (beyond chronic conditions) Nausea or Vomiting Diarrhea
Phone Number you can be reached at right now. *
Today's Date (Auto Populated)

Month Day Year
Date Hour Minutes AM/PM Option
Should be Empty:

Covid-19 Screening Questionnaire