CRL COVID-19 Pre-Screening Tool

1

Do you, or anyone attending with you, have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.* This field is required.Fever, chills, or cough; Difficulty breathing or shortness of breath; Sore throat or trouble swallowing; Runny nose/stuffy nose or nasal congestion; Decrease loss of smell and/or taste; Nausea, vomiting, diarrhea, abdominal pain; Not feeling well, extreme tiredness, sore muscles

YESNO

2

Have you or anyone attending with you had close contact with a confirmed or probable case of COVID-19?* This field is required.

YESNO

3

Since coming in close contact with a confirmed probable case, are you able to provide proof of a negative COVID-19 test?* This field is required.

YESNO

4

Have you, or anyone attending with you travelled outside of the country in the past 14 days?* This field is required.

YESNO

5

Since you have travelled outside of the country in the past 14 days, can you show proof of a negative COVID-19 test?* This field is required.

YESNO