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Shadow/Observer COVID Screening Form
Please be sure to submit this form no sooner than 72 hours (3 days) prior to your shadowing experience.
6
Questions
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1
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First Name
Last Name
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2
Do you have any signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat?
*
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YES
NO
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3
Have you received, or had contact with someone with a confirmed diagnosis or COVID-19 in the last 14 days?
*
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YES
NO
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4
Have you traveled internationally in the past 14 days?
*
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YES
NO
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5
Signature
*
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6
Date
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Date
Month
Day
Year
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