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.
*
Format: (000) 000-0000.
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AM/PM Option
Submit
Should be Empty: