Covid-19 Questionnaire
Required for workshop, tour, or safari participation
Name of
safari / tour / workshop
*
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Have you experienced any of the following symptoms that are not associated with any underlying medical condition or medication use.
*
Please Select
Shortness of breath
Loss of smell or taste
Muscle pain/body ache
Vomiting or abdominal pain
More than 3 loose stools in the last 24 hours
Sore throat
Onset of a severe headache
Fatigue
New uncontrollable cough
Loss of appetite
Congestion or runny nose
None of the above
Please enter the estimated date of any close contact that you have had a confirmed case of covid-19. Close contact is defined as being within approximately 6 feet (2 meters) of a confirmed Covid-19 case for at least 15 minutes. Please select "Not Applicable" if you have not been exposed to your knowledge.
*
-
Month
-
Day
Year
Date
Have you been vaccinated?
*
Yes
No
What type of Covid-19 test did you take?
blanks
*
Enter the date of your Covid-19 test
*
-
Month
-
Day
Year
Date
Enter the time your test
*
Hour Minutes
AM
PM
AM/PM Option
DECLARATION
*
I certify that I have answered truthfully to the best of my ability.
Submit
Should be Empty: