Health Survey - HIPAA compliant
Name *
(a) knowingly been in close contact in the past 14 days with anyone who has tested positive forCOVID-19 or who has or had symptoms of COVID-19; *
(b) tested positive for COVID-19 through a diagnostic test in the past 14 days; *
(c) experienced any symptoms of COVID-19 in the past 14 days; and *
(d) traveled within a state with significant community spread of COVID-19 for longer than 24hours within the past 14 days. *
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