COVID-19 Pre-Attendance Survey
In consideration of the well being of your family and others, if you plan to join us at ILC today, please take some time to fill out this survey. We appreciate your time in advance!
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Email *
Today’s Date *
La Fecha de Hoy
MM
/
DD
Attendee’s First and Last Name *
Primer nombre y apellido
Today, or in the past 24 hours, have you had any of the following symptoms?
- Fever, felt feverish, or had chills
- Cough
- Shortness of breath or difficulty breathing
- Muscle aches
- Fatigue
- Headache
- Sore throat
- Congestion or runny nose
- New Loss of taste or smell
- Gastrointestinal (diarrhea, stomach pain, vomit) *
Hoy, o en las últimas 24 horas, ¿ha tenido alguno de los siguientes síntomas?
- Fiebre, se sentía febril, o tenía escalofríos
- Tos
- Dificultad para respirar
- Dolores musculares
- Fatiga
- Dolor de cabeza
- Dolor de garganta
- Congestión o esrondos
- Nueva pérdida de sabor u olor
- Gastrointestinal (diarrea, dolor de estómago, vómitos)
In the past 14 days, have you had contact with a person known or suspected of being infected with the novel coronavirus (COVID-19) or displaying symptoms of COVID-19? *
En los últimos 14 días, ¿ha tenido contacto con una persona que a salido positivo o esta sospechada de estar infectada con el nuevo coronavirus (COVID-19)?
Have you had a viral test for COVID-19, and is the result unknown/pending at this time? *
¿Se ha hecho una prueba viral para COVID-19, y es el resultado desconocido/pendiente en este momento?
Do you currently have a temperature of 100 Degrees Fahrenheit (37.8 Celsius) or greater? *
¿Tiene actualmente una temperatura de 100 grados Fahrenheit (37.8 Celsius) o más?
Are you a Healthcare worker or Critical Infrastructure worker? *
¿Es usted un trabajador de la salud o de Infraestructura Crítica?
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