IMI Building Check-in (NO-PHONE)
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
1.) Have you been within 6 feet of a person with a confirmed case of COVID-19 in the past 14 days?
*
Yes
No
1a.) Has anyone in your household been advised to self quarantine?
*
Yes
No
2.) In the last 48 hours, have you had any of the following NEW symptoms?
2a.) Fever of 100.5 F (38 C) or above?
*
Yes
No
2b.) Fever symptoms like chills or sweating, or repeated shaking with chills?
*
Yes
No
2c.) Trouble breathing, shortness of breath or severe wheezing?
*
Yes
No
2d.) Cough?
*
Yes
No
2e.) Muscle aches?
*
Yes
No
2f.) Sore throat?
*
Yes
No
2g.) Loss of smell or taste, or a change in taste?
*
Yes
No
2h.) Nausea, vomiting or diarrhea?
*
Yes
No
2i.) Headache?
*
Yes
No
3.) Are you having any unexpected new symptoms?
*
Yes
No
4.) Have you traveled in the past 14 days?
*
Yes
No
Signature
Submit
Should be Empty: