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Covid-19 Health Screening
* Please fill this form out EVERY TIME you use the facility!
Full Name *
Is your temperature under 100.4 today? *
Have you knowingly been in close contact with anyone has tested positive for Covid-19 or has had symptoms of Covid -19, in the past 14 days? *
Have you tested positive for Covid-19 through a diagnostic test, in the past 14 days? *
Have you experienced any symptoms of Covid-19 in the past 14 days? *
Have you traveled within a state with significant community spread of Covid-19 for longer than 24 hours, within the past 14 days? *
Signature and Date *
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