COVID-19 Screening Form
Name
*
First Name
Last Name
Company
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any COVID-19 symptoms in the past 10 days?
*
Yes
No
Are you experiencing fever, chills, sweats?
*
Yes
No
Any headache, muscle aches, fatigue?
*
Yes
No
Any loss of taste or smell?
*
Yes
No
Any cough, shortness of breath, difficulty breathing?
*
Yes
No
Any nausea, stomach ache, vomiting, or diarrhea?
*
Yes
No
Any sore throat, congestion, runny nose?
*
Yes
No
Have you been in contact with any confirmed positive COVID-19 patients?
*
Yes
No
Have you traveled out of the area to a different state or country in the last 10 days?
*
Yes
No
I herby certify that the above statements are true to the best of my knowledge
*
Yes
Please verify that you are human
*
Submit
Should be Empty: