Mark Medical Care - COVID 19 Health Screening
The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which Mark Medical Care (the “Organization”) adheres to comply.

Employee/Visitor Health Screening
Sign in to Google to save your progress. Learn more
Date *
Location *
Have you experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell or shortness of breath within the past 10 days? *
In the past 10 days, have you tested positive for COVID-19 using a test that tested saliva or used a nose or throat swab (not blood test)? (10 days measured from the date you were tested, not the date you received the test result,) *
To the best of your knowledge, in the past 14 days have you been in close contact (6 feet for at least 10 minutes) with anyone while they have had COVID-19? *
In the past 14 days, have you traveled internationally or returned from a state identified by New York State as having widespread community transmission of COVID-19 (other than just passing through the restricted state for less than 24 hours)? Visit for applicable stated *
Your Name *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy