COVID-19 Screening Form
Check the conditions that apply to you (do not enter the facility until directed by staff):
One or more of these signs or symptoms that is new or not explained by another condition: fever (100.4 degrees F and above), chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, or diarrhea
"Close Contact" in the last 14 days with someone who has been diagnosed or had a positive COVID-19 test result or is awaiting COVID-19 test results
a positive COVID-19 test result from a test performed in the last 10 days
None of the above apply to me
If you checked a box for anything other than "None of the above apply to me," please do not enter the facility. This facility requires you to wear a mask and social distance while in the facility.
Should be Empty: