KairosPDX Health Questionnaire
Site Social Distancing Log & Self-Check for Building Access to Humboldt
Email address *
Please enter your first and last name *
In the past 30 days, have you or someone you live with been diagnosed with COVID-19? *
Required
Are you currently sick? *
Required
The symptoms we're most concerned about are any of the following: 1. Fever (>100.4°F or 38°C), chills or shivering/shakes 2.Cough 3. Sore throat 4. Difficulty breathing 5. Feeling unusually weak or fatigued 6. Unexplained muscle aches 7. Loss of senses of smell or taste 8. Runny or congested nose 9. Diarrhea (3 or more loose stools/24 hours) 10. Eye redness +/- discharge (Pink eye, not allergy)
In the past 14 days, have you had any of these symptoms which is new or not explained by a pre-existing condition?
In the past 14 days, have you returned from travel outside the U.S.?
In the past 14 days, have you been in unprotected close contact with someone diagnosed with COVID-19? (close contact = within 6 feet for 15 minutes or longer)
Do you currently have a fever (>100.4°F or 38°C)?
If you answered "NO" to all of the questions above you may proceed to the next log to register and sign the building entry log with your temperature.
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