2023 Post-Convention COVID Reporting Form

2023 Post-Convention COVID Reporting Form

Please take a COVID test ASAP and fill out this form to notify us of your status. If you test again and your status changes, please submit this form again.
Name*

First NameLast Name
DSA Membership Email*
example@example.com
Phone Number*
Did you attend 2023 DSA or YDSA Convention?*

DSAYDSABoth
Which of these describes you?*

DelegateAlternateObserverVolunteerSpeaker/guest
DSA and/or YDSA Chapter*
If you're an At-Large member, type At-Large. If not applicable, type N/A.
Since attending the DSA and/or YDSA Convention, have you experienced any cold or flu-like symptoms (to include fever, cough, shortness of breath or difficulty breathing, sore throat, pressure in the chest, extreme fatigue, earache, persistent headache, diarrhea, vomiting, muscle pain, chills, repeated shaking with chills, and persistent loss of smell or taste)? If you answer yes, we suggest that you get tested immediately.*

YesNo
Have you taken a COVID test since returning from Convention?*

YesNo, but I will test ASAPNo, and I don't plan to test
If you tested, what is your result?*

Positive COVID ResultNegative COVID ResultN/A
Is there anything else we need to know?
Should be Empty: