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Campaign Volunteer and Staff COVID Screening Form
Please complete this form prior to arriving at any in-person event.
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* Indicates required question
Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
If you answered yes to any of the questions below, please do not attend or participate in the event today.
1. Have you received a positive result from a COVID-19 test within the past 14 days or are you presently awaiting test results?
*
Yes
No
2. In the past 14 days, have you been in close contact with anyone who has or had symptoms of COVID-19 that required you to quarantine?
*
Yes
No
3. Are you currently experiencing a fever (100.4 or higher)?
*
Yes
No
4. Are you currently experiencing any of the following symptoms not attributable to another health condition: cough, loss of smell or taste, muscle aches, runny nose, shortness of breath, or sore throat?
*
Yes
No
Date of Form Completion
*
Your answer
Signature / Type Your Name
*
By typing your name below, you are certifying you have answered the questions above truthfully.
Your answer
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