Individual Covid Health Assessment
Please answer the following question and submit for each individual on the day of participation. ASDRA urges you to stay home and seek medical care if you test positive, are exposed through close contact, or exhibit any symptoms of Covid 19. To keep all of ASDRA members and volunteers safe please comply with the current State travel quarantine mandates.
Name
*
First Name
Last Name
Parent if applicable
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Have you traveled outside of Alaska in the last 14 days?
*
Yes
No
Have you come in close contact with anyone with Covid 19 in the last 14 days?
*
Yes
No
Have you had a fever over 100.4 in the last 72 hours?
*
Yes
No
Do you have an unusual sore throat or cough?
*
Yes
No
Are you experiencing unusual shortness of breath?
*
Yes
No
Do you have any of the following symptoms unexplained diarrhea, chills, abdominal pain, vomiting, fatigue, joint pain, muscle aches, new rash, loss of smell or taste, headache, new congestion or runny nose?
*
Yes
No
Submit
Should be Empty: